RN-Case Manager

Essential Duties & Responsibilities

• Performs client admissions, resumption of care, follow-up using OASIS data collection in a timely, legible, accurate manner.
• Responsible for monitoring and managing core measurements pertinent to the department to assure compliance with the operating plan.
• Identifies, documents and reports signs and symptoms of altered health status to physician and Clinical Team Manager.
• Obtains appropriate orders to increase/decrease visit frequency.
• Obtains medical orders to alter treatment plan.
• Develops Plan of Care consistent with clinical assessment findings, diagnosis, orders, HHRG Case Mix category, and appropriate utilization guidelines/clinical pathway specific to each client.
• Sets and evaluates attainable, specific, and measurable goals and outcomes.
• Administers meds and treatment according to Plan of Treatment.
• Teaches nursing care appropriate to client’s condition.
• Teaches based on client/caregiver level of understanding and is properly reflected in records.
• Collaborates with other health team members to coordinate care.
• Documents client records according to agency policy.
• Completes clinical notes, Plan of Care and medication records in a timely, legible and accurate manner.
• Notes progress towards discharge planning.
• Communicates with physician, and appropriate staff regarding discharge planning.
• Completes all discharge summaries according to policy and procedures.
• Supervises the LPN and Home Health Aide to ascertain compliance with Plan of Care.
• Makes supervisory visits in home at least every 14 days and documents visit in the clinical record to ascertain quality of care rendered.
• Utilizes knowledge of nursing, biological, social science, PPS, case management guidelines, and collaborative resources within the agency as well as outside the agency to assist with the development and /or revision to the Plan of Care to promote positive outcomes.
• Participates in back up call according to need of agency.
• Maintains safety precautions in compliance with OSHA, JCAHO/CHAP, and Federal and State standards.
• Operates medical equipment correctly for client care.
• Maintains current knowledge of nursing/home care as well as agency’s policies and procedures via in-services, testing, skills labs, and on-going CEU’s.
• Selects orients and assigns work for direct reports.
• Develops job design and performance standards, initiates and completes all elements of the Integrated Performance Management process, and makes recommendations for issues related to promotions, disciplinary actions and terminations.
• Updates management regarding potential problems or concerns.
• Maintains an understanding of the company’s scope of services.
• Participates in interdisciplinary conferences as required.
• SUBmits clinical documentation in a timely manner according to agency policy.
• Understands the infrastructure and how and where to transfer calls in the company.
• Maintains a professional image.
• Uses appropriate phone etiquette.
• Promotes a customer friendly atmosphere for all visitors and ensures client confidentiality at all times.
• Participates in accreditation program.
• Performs other duties as assigned.

Requirements

• Current RN license in the State of Florida.
• Current CPR certification.
• Current driver’s license and valid auto insurance.
• Completion of 25 CEU’s bi-annually.