RN Case Manager (RN) - Home Health

Key Responsibilities

• Oversees patient care from the beginning to the end of each episode
• Updates physician orders in the patient chart as needed
• Notifies physicians of any significant changes in patient condition
• Manages and coordinates multidisciplinary care, as applicable
• Provides skilled nursing care in the patient’s home as ordered by the physician
• Observes and monitors patient conditions
• Performs OASIS assessments to develop individualized care plans and adjusts them as needed
• Administers medications as prescribed
• Reduces re-hospitalizations through proactive interventions, including front-loading visits for high-risk patients
• Promotes continuity of care through appropriate admissions, transfers, and discharges
• Educates patients and families on disease processes and self-management strategies
• Involves patients and families in care plan development
• Teaches preventive measures to reduce re-hospitalizations
• Listens and responds to patient and family concerns
• Supervises care provided by LPNs and nurse aides
• Evaluates patient condition and treatment effectiveness against the plan of care
• Determines whether current care levels meet patient needs
• Communicates supervisory visit findings with LPNs and nurse aides
• Completes all clinical documentation in accordance with agency protocols and Medicare/Federal guidelines
• Documents all treatments, assessments, and patient education
• Maintains an active RN license
• Communicates schedule changes with the scheduler
• Participates in on-call rotations and case conferences
• Attends required in-services and agency meetings
• Travels to patient locations as scheduled
• Completes documentation for subsequent visits, discharges, evaluations, recertifications, and resumptions of care within 24 hours
• Completes start-of-care documentation within 24 hours
• SUBmits all required documentation within company-defined timelines
• FOLLOWS the plan of care within RN scope of practice regulations
• PERFORMS RN visits within assigned geographic areas per patient needs and regulatory requirements

Qualifications

• Active Registered Nurse (RN) license in the state of employment
• Minimum of one (1) year of RN experience in an acute care setting; home health experience preferred
• Valid driver’s license and auto insurance with the candidate listed as a driver
• Strong communication skills with the ability to build positive relationships with patients, families, physicians, and colleagues
• Strong attention to detail and observational skills
• Strong organizational skills with the ability to prioritize and meet deadlines
• Ability to follow direction and work collaboratively as part of a team