Compassionate Home Care RN Case Manager

JOB DESCRIPTION SUMMARY The registered nurse plans, organizes and directs home care services 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 assessment of patient and family to determine home care needs. • Provides a complete physical assessment and history of current and previous illness(es). • Regularly re-evaluates patient nursing needs. • Initiates the plan of care and makes necessary revisions as patient status and needs change. • Uses health assessment data to determine nursing diagnosis. Furnishes those services requiring substantial & specialized nursing skills. • Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative 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. • Counsels the patient and family in meeting nursing and related needs. • Provides health care instructions to the patient as appropriate per assessment and plan of care. • Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. • Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload. Communication • Prepares clinical notes and progress notes and updates the primary physician when necessary and at least every 60 days. • Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required. • Communicates with community health related persons to coordinate the care plan. • Participates in in-service programs and supervises and teaches other nursing personnel. 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. • Instructs, supervises, and evaluates home health aide care provided every two (2) weeks. Position Qualifications • Graduate of an accredited school of nursing. Previous home health/OASIS experience is a plus. • Current licensure in state, CPR certification and valid driver’s license. Current physical and TB test required. Must be able to pass a criminal background check. • Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.