Registered Nurse - RN Field Case Manager

RN Field Case Manager

JOB DESCRIPTION

Employees in this role serve as RN Field Case Manager. The employee, administrative supervision, works within general methods and procedures, exercising considerable independent judgement to select the proper course of action. The work requires knowledge of the policies, procedures, and regulations, and supervisory techniques, personnel policies, and procedures. The employee will report directly to the Clinical Director.

JOB DUTIES

• Must be able to adjust schedule to client needs, this may include evenings, nights and weekends.
• Performs initial and ongoing patient assessments in response to patients’ needs and in accordance with physician orders
• Initiates a written plan of care, re-evaluates and updates the plan as necessary
• Provides skilled nursing care within the nursing scope of practice
• Documents skilled care and/or services provided in compliance with federal and state laws and regulations, and Agency policies and procedures
• Initiates case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, to assure patient care needs are met.
• Addresses and supports patient/family cultural practices, as long as such practices do not harm others or interfere with the planned course medical therapy
• Promotes and provides patient/family/caregiver education using various verbal and written communication techniques that take into account the patient’s/family’s cultural, ethnic, and/or personal needs or preferences
• Supervises Licensed Practical Nurses at least every 30 days and must include a visit to the patient’s home with or without the LPN present.
• Supervises home health aides and ensures supervisory visits are performed every two weeks with or without the aide present, in the patient’s home.
• Supervises homemakers and companion as required by state law.
• Plans patient discharge appropriately; provides information about community resources to address patient ongoing needs
• Knowledgeable of federal, state regulations and Agency’s policies and procedures regarding patient care
• Coordinates patient care and/or services
• Communicates with all members of the health care team, including physicians appropriately and in a timely manner
• Notifies the physician and the Director of Nursing of any changes in the patient’s condition and the need to modify the plan of care
• Maintains currency of knowledge and skills
• Participates in the Agency’s Quality Improvement program
• Attends Agency meetings and in-service programs as required
• Obtains appropriate number of continuing education credits to maintain active RN license
• Maintains confidentiality of patient and Agency information at all times