Registered Nurse, Home Care Case Manager

About the role

Join PACE CNY as a Home Care Case Manager, RN! The Home Care Case Manager, RN is responsible for providing the highest quality of in-home care, ensuring safety at all times, and acts as a primary support to the Physician, Nurse Practitioner, Director of Clinical Services, and the Home Care Manager.

Responsibilities

• Provides quality care through assessment, development, implementation and evaluation of individualized participant care plans.
• Makes home visits to assess, organize, implement and evaluate participant care and reports changes and concerns to the provider and documents appropriately.
• Reviews the order inbox in TruChart or similar software daily.
• Obtains, transcribes and implements physician orders timely and appropriately.
• Demonstrates appropriate knowledge and skill while performing quality care and meeting the participant specific needs, as evidenced by appropriate documentation and implementation of Pathways as needed.
• Observes and assesses for changes in clinical and/or functional status and appropriately initiates follow-up actions.
• Teaches and counsels participants and caregivers as needed regarding maintenance of health and prevention of illness or complications.
• Provides appropriate education to participant and family and initiates a teaching plan as needed.
• Uses educational handouts.
• Evaluates effectiveness of teaching plan and readjusts as needed.
• Provides appropriate education to staff as evidenced by documentation of needed competencies and documentation of orientation to the care plan.
• Delegates tasks appropriately and supervises, instructs and guides nursing and paraprofessional staff in providing high quality nursing services.
• Delegates tasks appropriately to the specific discipline.
• Supervises all tasks delegated.
• Educates and monitors all delegation of special circumstance tasks.
• Completes and documents aide supervisions in a timely manner.
• Responds appropriately to Aide communications in a timely manner and investigates the issues as needed.
• Includes Home Health Aides and LPN’s and/or their feedback in care planning meetings.
• Collaborates/coordinates with the Rehabilitation department for Safe Participant Handling solutions.