RN Case Manager
Job Description TITLE OF POSITION: REGISTERED NURSE TITLE OF IMMEDIATE SUPERVISOR: Director of Nursing Benefits: Health Insurance, Dental Insurance & Vision Insurance 401K dollar for dollar matching PTO, Sick Leave and National Holiday pay Company Care with EZPass and Gas card Employee discounts RISK OF EXPOSURE TO BLOODBORNE PATHOGENS - HIGH DUTIES To provide nursing care in accordance with the client's plan of care to include comprehensive health and psychosocial evaluation, monitoring of the client's condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care. RESPONSIBILITIES Coordinate total client care by conducting comprehensive health and psychosocial evaluation, monitoring the client's condition, promoting sound preventive practices, coordinating services and teaching and training activities. Evaluate the effectiveness of nursing service to the client and family on an ongoing basis. Perform admission, transfer, re-certification, resumption of care and discharge OASIS for the home care client. Prepare and present client's record to the Clinical Record Review Committee as indicated. Consult with the attending physician concerning alterations of client care plans, checks with the appropriate supervisor and makes changes, as appropriate. Coordinate client services. Submit clinical notes no less often than weekly, and progress notes and other clinical record forms outlining the services rendered as indicated. Submit a tally of client care visits made each day. Participate in case conferences, discuss with the supervisor problems concerning the clients and how they may best be handled. Discuss with the appropriate supervisor the need for the involvement of other members of the health team such as the Home attendant, the Physical Therapist, the Speech Therapist, the Occupational Therapist, The Medical Social Worker, etc. Obtain orders for paraprofessional service and submits a referral to the appropriate personnel. Participate in the client's discharge planning process. Cooperate with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan. Participate in staff development meeting. Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations and individual research and reading. Participate in the development and periodic revision of the physician's plan of treatment and processes change orders as needed Submit clinical notes within seventy-two (72) hours, and progress notes and other clinical record forms outlining the services rendered. Participate in the client's discharge planning process. Maintain an on-going knowledge of current drug therapy. Adhere to Federal, State and accreditation requirements including Medicare and Medicaid regulations. May be requested by Director of Nursing to fill in for the other nurses. COORDINATES THE ADMISSION OF A CLIENT TO THE AGENCY Conduct an initial and ongoing comprehensive assessment of the client's needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points. Obtain a medical history from the client and/or a family member particularly as it relates to the present condition. Conduct a physical examination of the client, including vital signs, physical assessment, mental status, appetite and type of diet, etc. Evaluate the client, family member(s) and home situation to determine what health teaching will be required. Evaluate the client's environment to determine what assistance will be available from family members in caring for the client. Evaluate the client's condition and home situation to determine if the services of a Home Attendant will be required and the frequency of this service. Explain nursing and other agency services to clients and families as a part of planning for care. Develop and implement the nursing care plan. May be requested by the Director of Nursing to fill in for other nurses who are on vacation or sick. PROVIDES SKILLED NURSING CARE AS OUTLINED IN THE NURSING CARE PLAN Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician. The initiation of preventative and rehabilitative nursing procedures as appropriate for the client's care and safety. Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, as well as changes in the client's physical or emotional condition. Teaching, supervising and counseling the client and caregivers regarding the nursing care needs and other related problems of the client at home. ASSUMES RESPONIBILITY FOR THE CARE GIVEN BY THE HOME ATTENDANT Supervise and evaluate the care given by the Home Attendant as needed, and at a minimum of once every 14 days. Submit to the appropriate department/individual, a written evaluation of the Home Attendants who are providing service to the clients in his/her geographical area. Participate in periodic conferences with the Home Attendant supervisor concerning the HA's performance. Chart those services rendered to the client by the staff nurse and changes that have been noted in the client's condition and/or family and home situation, makes revisions in the nursing care plan as needed, records supervisory visits conducted with the Home attendant, evaluates client care and progress and closes charts of discharged clients. Evaluate the effectiveness of her nursing service to the individual and family. Consult with the attending physician concerning alteration of the plan of treatment in consultation with the supervisor. Submit clinical notes no less often than weekly, and progress notes and other clinical record forms outlining the services rendered as indicated. Submit a tally of visits made each day. Participate in case conferences. Discuss with the supervisor problems concerning the clients and possible resolution. Discuss with the supervisor the need for involvement of other members of the health team such as the home attendant, physical therapist, speech therapist, occupational therapist, social worker, etc. Obtain orders for paraprofessional service and submits referral to appropriate personnel. Provide guidance and supervision to the LPN and supervises the LPN once monthly. Coordinate total client care. Cooperate with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan. Participate in staff development meetings. Participate in the educational experiences for student nurses. Continually strive to improve his/her nursing care by attending in-service education, through formal education, attendance at workshops, conferences, goal setting, active participation in professional and related organizations and individual research and reading. Participate in the planning, operation and evaluation of the nursing service. Participate in the development and periodic revision of the physician's plan of treatment and processes change orders as needed. Participate in the client's discharge planning. Submit clinical notes no less often than weekly, and progress notes and other clinical record forms outlining the services rendered as indicated. Maintain an on-going knowledge of current drug therapy. Prepare the care plan for the Home attendant. JOB CONDITIONS Must have a driver's license and be willing and able to drive to client's residences. The ability to access clients' homes which may not be routinely wheelchair accessible is required. Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment of the client's condition and to perform and demonstrate client care. Physical activities will include, walking, sitting, stooping, and standing and minimal to maximum lifting of clients and the turning of clients. The ability to communicate effectively both verbally and in writing in English, is required as frequent communication by telephone and in writing is required. EQUIPMENT OPERATION Thermometer, B/P cuff, glucometer, penlight, hand washing materials. COMPANY INFORMATION Has access to all client medical records, personnel records and client financial accounts which may be discussed with the Director of Nursing. QUALIFICATIONS 1. Must be a graduate from an accredited School of Nursing. 2. Must be licensed in Virginia as a Registered Nurse. 3. A minimum of one year experience in community/home health agency or hospital setting, prefer home care. 4. Must have knowledge of Medicare regulations/guidelines. 5. Must have a working knowledge of home health care and the principles and techniques of professional nursing and required documentation that pertains to it. 6. Skillful in organization and in the principles of time management and have knowledge of management processes. 7. Must be able to contribute to the quality of care being rendered through constructive communication with nursing managers and staff. 8. Must have a criminal background check. 9. Must have a current CPR certification. Company Description NHC is a fast growing company that lays great emphasis on the staff hired. NHC goes above and beyond to offer a great work atmosphere to provide the highest level of satisfaction at work. Bedford is our newest location and will cover the surrounding counties.