RN Case Manager (Watertown/Belmont, PM)

FLSA Classification:Exempt

Department:Clinical

Reports To:Clinical Manager

Direct Reports:N/A

POSITION SUMMARY:

The Case Manager Registered Nurse (RN) is responsible for partnering with the Clinical Director and team to administer and coordinate skilled nursing care to patients requiring home care services. Services are provided in accordance with physician’s orders, under the direction and supervision of the Clinical Director and in compliance with applicable laws and regulations and the policies of the organization.

RESPONSIBILITIES:

Clinical Care:

• Provides direct care and case management of assigned patients, including initial assessment and development of plan of care, as well as oversight and administration of prescribed medications and treatments. Maintains and updates schedules of all disciplines in patient’s home.
• Consistently assesses and evaluates patient’s status and goals and revises the plan of care as necessary. Communicates adjustments to plan of care to all team members in the appropriate time frame to support consistent delivery of care. Complete authorization modifications in a timely manner, where needed.
• Initiates and applies appropriate preventative, therapeutic, and rehabilitative procedures and maintains communication regarding patient care with the physician, supervisory personnel, and other professional staff involved in patient care.
• Consistently monitors and manages patient medications; maintains an accurate medication profile; coordinates prescription refills with physicians and pharmacies and picks up medication refills as needed.
• Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet, and other instructions as ordered by the physician. Recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
• Provides and maintains a safe environment for the patient. Reports unsafe conditions, complaints and incidents on behalf of patient as appropriate.
• Observes and supervises Home Health Aide & LPN to evaluate performance and quality of care.
• Accepts responsibility of assignment to perform a specialized procedure, such as IV therapy, when qualified with appropriate training and proven competency in the delivery of the therapy.
• Uses supplies and equipment effectively and efficiently. Maintains equipment per agency policy.
• Fulfills the obligation of assigned patient case load including tracking of patient status when transferred, following up with other healthcare facilities providing care to patients, resuming care of patients when appropriate.
• Adheres to HIPAA laws and maintains patient confidentiality always.

• Other duties assigned by the case manager/clinical management, i.e., performing field supervisions of care team members as required by agency policies.
• Performs other duties as assigned.

Documentation:

• Completes and submits accurate, timely clinical notes including all OASIS documents, visit authorization requests, physician orders, and all other clinical documentation regarding patient’s condition and care provided in accordance with Innovive company policies.

Communication and Meetings:

• Communicates with physicians and other agencies providing nursing or related services on a consistent basis to ensure continuity of care and implementation of a comprehensive care plan. Acts as part of the interdisciplinary care team.
• Participates in scheduled clinical and internal/external case management meetings. Attends vendor and referral meetings as needed and assigned, or as patient conditions require. Documents all meetings and outcomes for patient medical record.
• Coordinates with pharmacies, insurance companies and other service providers as needed to facilitate timely and appropriate provision of patient care.

COMPETENCIES:

• Effective communication skills (verbal and written), documentations skills, interpersonal skills, and problem-solving skills.
• Demonstrates organizational and assertiveness skills, flexibility and ability to work effectively in teams.
• Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
• Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Completes tasks on time or notifies appropriate person with an alternate plan.

REQUIRED QUALIFICATIONS:

• Graduate of an accredited school of professional nursing
• Is currently licensed as an RN through the State Board of Nursing and meets one of the following criteria:
  • RN with a bachelor’s degree in nursing and one year of related working experience
  • RN with a diploma or associate’s degree with two years related work experience

• Has passed the National Council Licensure Examination (NCLEX)

• Complies with accepted professional standards and principles
• 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, or other reliable means of transportation
• Possesses and maintains CPR certification
• Has presented a pre-employment physician’s health clearance including negative TB skin test and/or CXR and other tests as required by organization policy
• Has satisfactory references from nursing school, previous (or current) employers and/or professional peers

Preferred Education and Experience:

• Prior experience caring for mental health patients
• 1-2 years’ experience in a home health environment

Continuing Education Requirements:

Agency personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, agency personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All agency personnel must attend mandatory education programs.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

• Frequently required to stand.
• Frequently required to walk.
• Frequently required to sit.
• Continually required to use hands and fingers. 
• Frequently required to climb, balance, bend, stoop, kneel or crawl.
• Occasionally required to lift/push light weights (less than 25 pounds).
• Occasionally required to lift/push light weights (greater than 25 pounds).
• Moving, lifting, or transferring of patients may be required on occasion.
• Frequent exposure to bloodborne and airborne pathogens or infectious materials.