Registered Nurse, Case Manager

Registered Nurse Clinical Care Manager shall perform, but not be limited to, the following: 1. Performs initial patient assessments, obtains all necessary authorizations and consents, and develops and institutes the patient’s care plan at initial visit. 2. Initiate appropriate preventive and rehabilitative nursing procedures and makes appropriate referrals. 3. Re-evaluate the patient’s nursing needs on each visit, reviewing and updating the physician orders as required. Inform the physician, assigned nursing personnel and Clinical Supervisor of changes in the patient’s condition and needs. 4. Instruct the patient, family and assigned nursing personnel in meeting nursing and related needs. 5. Clinical documentation for each visit to include a patient physical assessment with emphasis on evaluation of goals and patient plan. 6. Prompt reporting of any and all incidents, patient/family/staff concerns, requests or needs to Clinical Supervisor. 7. Provides instruction to other staff members, patient and family members or patient representative in accordance with the plan of care. 8. Update the Plan of Care minimally every 60 days and as required. 9. Update the Medication Profile every 60 days and as required. 10. Assessment of patient with cognitive neurodegenerative diseases, including but not limited to anxiety and dementia (e.g. Alzheimer’s, dementia, Parkinson’s). 11. Monitors prescribed medications, making recommendations and facilitating changes. 12. Observes and reports behavioral changes to physicians involved in POC. 13. Helps patients improve their coping abilities. 14. Work with patient’s family/caregiver to help improve patient’s abilities and help them deal with their family member’s mental condition. 15. Builds relationships with patients to encourage trust, while listening to and interpreting their needs and concerns. 16. Responds to distressed patients in a non-threatening manner and attempts to understand the source of distress. 17. Applies “de-escalation” techniques to help patient manage their emotions and behaviors. 18. Participate in patient team conferences two times a month or/as required. 19. Monitors patient charts weekly to assure that care plan revisions have been incorporated into clinical record. 20. Assures that accurate transcription and implementation of physician’s orders have been recorded. 21. Monitors documentation of discharge planning activities and assures that discharge summary is written in a timely fashion. 22. Initiates and facilitates conferences on a regular basis with caregivers regarding patient progress and plan revisions. 23. Communicates and works cooperatively with other member’s of health care team. 24. Overflows patient visits to Scheduler for assignment to LVN’s, during the week and weekends. 25. Establishes and maintains effective communication regarding patient’s care with patient and family members. 26. Attends, participates in and/or conducts internal staff development programs. 27. Maintains and enhances clinical practice skills through external continuing education and conferences. 28. Provides leadership and direction to ancillary personnel as assigned. 29. Trains home health aides in personal care skills as needed. 30. Provides bi-weekly supervisory visits to the patient to assess quality of Home Health Aide services provided. 31. Perform supervisory visits of HHA every two weeks. 32. Follows infection control and safety measures at all times 33. Prepares and submits timely written reports of client’s evaluation, visits, summaries, care plans and care conference notes. Note: Submission of clinical documentation, visit slips and/or daily time summaries is required for satisfactory completion of an assignment as defined by agency policy. Failure to provide this documentation will result in disciplinary action. 34. Maintains confidentiality regarding clients, health care staff and documentation. 35. On-call rotation