RN Case Manager- Home Health

About the role

Transform Healthcare through clinical excellence in a community-based healthcare network encompassing seven hospitals, including a U.S. News & World Report Top 10 Hospital and two Magnet®-designated hospitals, multi-specialty physician practices, and affiliations with prestigious academic medical institutions.

Responsibilities

• Affectionately assesses, plans, implements, and evaluates patient care to achieve optimum patient outcomes for patients of all ages as appropriate to service area.
• Understands Hospice concept of care and the complex issues related to caring for the terminally ill.
• Provides competent, compassionate care in a variety of settings.
• Collaborates with other members of the health care team/patient/family to develop, implement, and evaluate an age-specific interdisciplinary plan of care.
• Revises plan according to changes in patient status.
• Administers and documents treatments and medications for patients utilizing automated computer systems, including electronic medical records.
• Ensures patient care orders are current, accurate, implemented, and evaluated for effectiveness per provider order.
• Identifies patient/family (caregiver) educational needs, incorporates education into the plan of care, and documents.
• Contributes to Carilion Clinic’s performance improvement activities.
• Advocates for patient, protects patient’s rights, and provides psychological/social/cultural support.
• Plans, coordinates, and provides clinical care in a way that promotes positive patient outcomes, promotes safety during vulnerable periods of transition, and upholds a culture of patient centered care.
• Exhibits clinical expertise in rapidly changing circumstances.
• Plays a role in preventing avoidable re-hospitalizations, reducing length of stay, turnaround time, resource consumption, and improving patient outcomes.
• Sets priorities, modifies environment to meet patient care needs, manages resources, and completes manager/director predetermined projects within specified time frame and according to pre-established guidelines.
• Facilitates resolutions for patient and work situations.
• Might provide orientation to new employees.
• Might supervise LPN as required per regulatory guidelines.
• Keeps case management worksheet up to date.
• Manages case conferences on assigned patients.
• Might supervise Home Health Aides and evaluations.
• Safeguards visit frequencies reflecting orders and appropriate with evidence-based practice.
• Collaborates with centralized scheduling to ensure appropriate adjustments to visit frequencies are made as needed.
• Collaborates with billing to ensure pre-authorization is appropriately secured and patient financial obligations are communicated.
• Performs skilled visits including OASIS visits as needed.
• Creates new plan of care 485/486.
• Coordinates appropriate provision of BIPA and ABN forms or any others as directed by CMS or agency policy.
• Utilizes Mifi device to access information promoting quality of care and continuity.

Requirements

• Graduate of accredited Registered Nurse Program.
• Currently licensed as Registered Nurse in the state of Virginia or approved compact state.
• Valid driver’s license, automobile insurance, and personal vehicle for making home visits.
• Keyboarding skills required for automated computer systems, including electronic medical records.
• Demonstrates knowledge of the principles of life span growth and development and assesses data reflective of the patient’s status.
• Interprets the appropriate information needed to identify each patient’s requirements relative to his or her age specific needs and provides care according to departmental policies and procedures.

Qualifications

• Strong critical thinking skills are necessary and needed to interpret laws and regulations related to CHCS and Carilion Clinic.
• Applies knowledge of growth and development to appropriately care for patients served.

Skills

• Delegation and critical thinking skills.
• Team-oriented, collaborative approach to patient care.
• Advanced knowledge and skills of patient care.
• Knowledge of growth and development.

Benefits

• Comprehensive Medical, Dental, & Vision Benefits.
• Employer Funded Pension Plan, vested after five years (Voluntary 403B).
• Paid Time Off (accrued from day one).
• Onsite fitness studios and discounts to our Carilion Wellness centers.
• Access to our health and wellness app, Personify Health.
• Discounts on childcare.
• Continued education and training.