The RN Case Manager is the member of the interdisciplinary team who is the pivotal person in identifying the physical, psychological, social and spiritual needs of the patient and family. RN Case Manager initiates appropriate intervention and support for the patient and family upon admission and provides a continuously appropriate, comprehensive and responsive plan of care.
Essential Job Functions/Responsibilities:
Case Management and Supervision
• Coordinates the patient’s and families care and services including those of the team, social worker, licensed vocational nurse, home health aide and physician.
• Responds necessary information to the senior case manager.
• Monitors the re-certification / re-authorization process.
• Participates in Interdisciplinary Team Meetings as indicated.
• Ensures and documents appropriate use of the medications, durable medical equipment and supplies.
• Educates patients, families and other caregivers.
• Provides skilled nursing as determined by the interdisciplinary plan of care.
• Appropriately utilizes the skills and resources of contract personnel such as PT, OT, Dietary, Speech and Pharmacy.
• Provides appropriate care plan and integrates care plans as needed.
• Performs on site evaluations of Certified Home Health Aides (CHHA).
• Participates in the on-call rotation and weekends.
• Integrates QI results into the established plan of care.
• Participates in QI assessment routinely.
• Participates in proactive patient calls.
• Participates in routine chart reviews.
• Participates in the orientation of new team members as assigned by the Team Manager.
• Attends regularly scheduled in-services and educational conferences.
• Develops and achieves professional growth goals and objectives and reviews with the Team Manager.
• Represents professional nursing.
• Excellent observation, diagnostic, medication management and clinical documentation skills
Professional Requirements and Required Certification/Licensure
• Current/valid Registered Nurse license in the State of California.
• Two to three years of hospice or home health nursing experience.
• Knowledge of State and Federal regulations relating to hospice or home health participation.