Registered Nurse Case Manager - Home Health - Full Time - Marin County

Req #420

Job Description Summary

The Registered Nurse Case Manager plans, organizes and directs care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. 

Essential Job Functions/Responsibilities

Patient Care: 

• Completes an initial, comprehensive, and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). 
• Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act. 
• Assesses and evaluates patient’s status by writing and initiating plan of care. 
• Writing and initiating plan of care 
• Regularly re-evaluating patient and family/caregiver needs 
• Participating in revising the plan of care as necessary 
• Initiates the plan of care and makes necessary revisions as patient status and needs change. 
• Uses health assessment data to determine nursing diagnosis. 
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. 
• Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care. 
• Counsels the patient and family in meeting nursing and related needs. 
• Provides health care instructions to the patient as appropriate per assessment and plan. 
• Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self- sufficiency and optional comfort care. 
• Maintain current documentation on EMR system according to organization policies/procedures and applicable laws/regulations. 
• The RN Case Manager, when assigned by the Clinical Manager/DPCS, assumes responsibility to coordinate patient care for an assigned case load. 
• The Admission RN may act as Case Manager when assigned by Clinical Manager/DPCS and assumes responsibility to coordinate patient care for assigned caseload. 
• The RN Case Manager may act as an Admission Nurse when assigned by Clinical Manager/DPCS and assumes responsibility to coordinate with intake, program staff and management to complete a patient initial admission/assessment with plan of care. 

Communication: 

• Completes, maintains, and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate. 
• Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required. 
• Communicates with community health related persons to coordinate the care plan. 
• Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group. 
• Provides and maintains a safe environment for the patient. 
• Assists the patient and family/caregiver and other team members in providing continuity of care. 
• Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver. 
• Attends interdisciplinary group meetings. 

Additional Duties: 

• Participates in on-call duties as defined by the on-call policy. 
• Ensures that arrangements for equipment and other necessary items and services are available. 
• Supervises ancillary personnel and delegates responsibilities when required. 
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and Inservice classes. 
• Fulfills the obligation of requested and/or accepted case assignments. 
• Actively participates in quality assessment performance improvement teams and activities. 
• Must adhere to the company attendance and reliability guidelines, which are an essential function of the job to ensure quality, and consistent patient care. 

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbent(s) of this job. The incumbent(s) may be requested to perform job related tasks other than those stated in the description

Job Qualifications:

• A graduate of a National League of Nursing accredited school of nursing. 
• Current licensure in state of practice and current CPR certification. 
• Must possess a valid California Driver’s License and can show proof of valid auto insurance. 

California only: 

• May have an RN license and practiced as an RN for a minimum of one year with prior LVN experience in public health, home care, Hospice, Hospital or Skilled nursing facility.  

All States: 

• Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years OR (b) have a baccalaureate degree in nursing from a program accredited by the National League for Nursing and a current RN license. A minimum of two years’ experience, at least one of which is in public health, home care, or hospice nursing is preferred. 
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order. 
• Management experience not required. Responsible for supervising hospice aides. 
• Self-directed and able to work with minimal supervision. 
• Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist. 
• Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stop bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills. 

Physical Requirements:

• The ability to sit occasionally for 1-3 hours. 
• The ability to frequently stand for 3-6 hours. 
• The ability to occasionally drive/ operate foot control for 1-3 hours 
• The ability to walk intermittently on level and or unlevel surface for less than 1 hour 
• The ability to intermittently bend or climb for less than 1 hour. 
• The ability to occasionally twist, kneel, crouch and crawl for 1-3 hours 
• The ability to lift 50 pounds frequently for 3-6 hours 
• The ability to lift greater than 50 pounds occasionally for 1-3 hours. 
• The ability to carry up to 50 pounds frequently for 3-6 hours. 
• The ability to carry greater than 50 pounds occasionally for 1-3 hours. 
• The ability to push up to 50 pounds frequently for 3-6 hours. 
• The ability to push greater than 50 pounds occasionally for 1-3 hours. 
• The ability to pull up to 50 pounds frequently for 3-6 hours 
• The ability to pull greater than 50 pounds occasionally for 1-3 hours.