Judson Link Case Manager

About the role

Provides and oversees residents who live in Judson community to assure the maximum health and wellness, autonomy, and quality of living for them is restored or maintained. Provides supervision and guidance to associates providing direct care services to Judson at Home residents. Serves as liaison between Judson and the community regarding resident needs. Responsibilities include development and promotion of Judson at Home programs and services while maintaining the standards of practice consistent with quality of community care. Works collaboratively with the team to provide coordinated care. Self-direction in maintaining the standards of practice in order to maintain maximum wellness and independence of the clients served through Judson at Home.

Responsibilities

• General Home Health duties:
  • Makes home visits to prospective JAH members – for assessment and alignment with appropriate level of care.
  • Monitors resident/community client appropriateness in current level of care, assesses and advises when other services may be appropriate.
  • Delivers and coordinates case management services; and making referrals for other services accordingly.
  • Effective communication with residents and families. Actively listens to resident and family concerns and identifies solutions.
  • Participates in Quality Improvement initiatives.
  • Initiates or participates in care conferences and maintains effective communication with interdisciplinary teams.
  • Insures that all information is updated and assessable within the EMR. Completes intake, assessments and development of plan of care for JAH members receiving home care services. Monitors care delivery and makes changes as needed to care plan for JAH home care clients.
  • Maintains required documentation including developing, implementing and evaluating the care plan, as changes in condition occur and as required.
  • Oversight of care delivered by the home care aide and makes adjustments to plan of care as needed. Coaches the home care aid to improve care delivery.
• Home Care duties:
  • Completes intake, assessments and development of plan of care for residents receiving home care services. Monitors care delivery and makes changes as needed to care plan for home care clients.
  • Maintains required documentation including developing, implementing and evaluating the care plan, as changes in condition occur and as required.
  • Oversight of care delivered by the home care aide and makes adjustments to plan of care as needed. Coaches the home care aid to improve care delivery.
• Judson at Home Community duties:
  • Maintain schedule of home visits and contact for residents of that community.
  • Offer health counseling and be available to residents in the capacity of listening to concerns and problems.
  • Introduces new residents to various levels of care and obtains necessary medical and contact information ie: Advanced Directives. Updates contact and emergency information as necessary.
  • Coordinates care and care transitions and serves as liaison as resident requires alternative services working collaboratively with the social worker at each community.
  • Completes annual updates or more frequently if necessary, resident face sheets to include diagnosis, medications and contact information for physicians, emergencies and contacts as well as advanced directives.
  • Collaborates with the customer service manager regarding concierge and other non-health related concerns.
  • Collaborates with the administrative and marketing team regarding potential member needs and options for expansion of services.
  • Serves as the main point of contact for resident health care needs.
• Other Duties:
  • Conducts employee supervisory visits which monitors competency levels of care provided by HHAs to residents/community clients.
  • Provides on-call coverage after hours and is therefore required to carry pager and have access to a phone at all times. Responds promptly to all pages resolving all clinical care situations in association with existing cases.
  • Prepares and submits monthly documentation for billing.
  • Maintains a record of acceptable attendance and punctuality.
  • Observes all company rules and safety procedures.
  • Other duties as assigned.

Qualifications

• Current Registered Nurse (RN) license with three years nursing experience and one year supervisory.
• Community/home care experience is required with case management experience preferred or willingness to become certified.
• Must possess a valid Ohio driver's license.
• Proven record of reliability, dependability, accuracy and attention to detail, excellent interpersonal and communication skills.
• Good assessment, analytical and problem-solving skills.
• Must have an understanding and acceptance of the philosophy of care of JHC.
• Managerial experience regarding hiring, discipline, performance appraisals, etc.
• Proficiency on windows-based computer word processing and spreadsheet software is necessary.

Physical requirements

• Requires good vision, hearing, speech and communication skills with the ability to ambulate, project voice, use the telephone, use the computer and read and write English.
• Must be able to stand on her/his feet for a period of up to eight (8) hours a day, move around the home without difficulty, transfer a 150-pound person and squat on the floor and rise to standing.

Working conditions

• The office-working environment is conducive to be able to computerize essential data, communicate effectively on the telephone and communicate effectively with referrers, caregivers, supervisors, R/Cs and responsible or interested parties.
• When away from the office, must be within paging and (cell) telephone range to effectively communicate scheduling changes. Also, must have access to updated information (i.e. employee, supervisor and resident data) at all times.
• Individual home-work environments may vary and include: pets, smoking, family members, traveling to various locations, and other conditions as dictated by the individual environment. Each home or residence has a "Home Safety Evaluation" conducted at the admission of each case by the RN Community Care manager to confirm that the home environment is safe and to make recommendations as necessary.
• Flexibility in work hours may be necessary.