Alaska, Healthcare, Industry

RN Case Manager Anchorage, AK

The Registered Nurse Home Health and Hospice Case Manager plans, organizes and coordinates the care of all assigned cases. The RN Home Health and Hospice Case Manager, in consultation with other disciplines/professionals, select outcome goals and skilled interventions. The RN Home Health and Hospice Case Manager effectively use agency and community resources, to achieve patient and family independence with patient care, in the patient’s place of residence. The RN Home Health and Hospice Case Manager coordinate the services of all disciplines to achieve outcome goals established by the team.

REPORTS TO: Clinical Supervisor/Branch Director

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES

— PATIENT CARE —

  • Maintains working knowledge of current home health and hospice coverage guidelines, admission criteria, documentation requirements, coding guidelines and care planning with IDG/IDT; manages patient care accordingly.
  • Determines patient eligibility for admission and recertification based on admission and recertification guidelines, and regulatory requirements and the suitability /adaptability /safety of the patient’s home for hospice or home care delivery.
  • Effectively manages initial home visit; introducing services, admission criteria, process for determining patient eligibility and for obtaining required consents when eligibility is confirmed.
  • Assesses the patient/caregiver willingness/ability/barriers to learn patient care techniques and for achieving independence in care; documents patient/family response to teaching.
  • Outlines Aide care plan, as applicable; performs ongoing home health aide oversight, revises Aide Care Plan based on patient progress; evaluates home health aide care every 14 days or per state payer requirement and state regulations.
  • Supervises LPN participation in patient’s plan of care and performance of skilled interventions at intervals defined by state regulations.
  • Initiates the plan of care and related nursing interventions; conducts goal-oriented visits; ensures other nursing team members have information needed for continuity of care and continued progress.
  • Provides patient/family teaching per POC; assesses and documents response to teaching Advocates for the patient as required.
  • Determines patient eligibility for admission and recertification based on admission and recertification guidelines, and regulatory requirements and the suitability /adaptability /safety of the patient’s home for hospice or home care delivery
  • Effectively manages initial home visit; introducing services, admission criteria, process for determining patient eligibility and for obtaining required consents when eligibility is confirmed.
  • Assesses the patient/caregiver willingness/ability/barriers to learn patient care techniques and for achieving independence in care; documents patient/family response to teaching.
  • Outlines Aide care plan, as applicable; performs ongoing home health aide oversight, revises Aide Care Plan based on patient progress; evaluates home health aide care every 14 days or per state payer requirement and state regulations.6. Supervises LPN participation in patient’s plan of care and performance of skilled interventions at intervals defined by state regulations.
  • Initiates the plan of care and related nursing interventions; conducts goal-oriented visits; ensures other nursing team members have information needed for continuity of care and continued progress.
  • Provides patient/family teaching per POC; assesses and documents response to teaching.
  • Advocates for the patient as required.

PATIENT CARE – Home Health

  • Completes an accurate, initial comprehensive head to toe assessment. Completes for Home health patients an OASIS and other assessments of patient and family to determine home care needs; obtains a history of current and previous illness(es).
  • Uses health assessment data, input from agency team members, the physician, patient and family, to determine patient needs.
  • Effectively manages patient and family expectations regarding agency services, outcomes/discharge goals and ability to achieve independence in care.13. Establishes appropriate primary and secondary diagnoses based on patient assessment and focus of home health care.
  • Develops a care plan, incorporating appropriate skilled interventions, and necessary medical supplies/equipment and ancillary/specialty services, to achieve outcome/discharge goals.15. Projects realistic home health visits by discipline and medical supplies required per planned interventions and discharge goals, write POC orders accordingly.16. Regularly evaluates home health patient’s progress, in collaboration with team members; revises patient POC accordingly.
  • Performs ongoing appropriate OASIS assessments and revises POC accordingly.
  • Identifies home health patient’s discharge planning needs when developing the plan of care; identifies and implements community referrals prior to patient discharge; determines patient readiness for discharge based on expected outcomes, goals and coverage guidelines.

PATIENT CARE – Hospice

  • Completes an accurate, initial comprehensive head to toe assessment.
  • Coordinates and plans with interdisciplinary group additional assessments of patient and family to determine hospice care needs.
  • Uses the palliative care model, seeks input from IDG/IDT, physician and the patient and family goals for disease course to determine the plan of care and establishing outcomes.
  • Effectively manages patient and family palliative expectations regarding agency services and works with IDG/IDT and patient/family/caregivers to deliver effective, efficient and desired outcomes.
  • Manages proper utilization of hospice resources and implements IDG/IDT approved (ordered) interventions.
  • Coordinates and delivers IDG/IDT’s approved (ordered) care plan, incorporating appropriate skilled interventions, and necessary medical supplies/equipment and ancillary/specialty services, to achieve desired outcomes.
  • Projects realistic visits by discipline and medical supplies required per IDG/IDT’s planned interventions and desired outcomes.
  • Regularly evaluates hospice patient’s progress, in collaboration with IDG/IDT; who revise patient POC accordingly.
  • Administers medications and treatments as prescribed by the physician, IDG/IDT and per patient’s POC.
  • Identifies desired hospice patient’s desired outcomes when developing the plan of care; identifies and implements community referral support.

— COMMUNICATION/CARE COORDINATION —

  • Prepares clinical notes and other required documentation within required timeframes.29. Obtains/receives physician orders as requirement for treatment changes; communicates new/changed orders to appropriate team members.
  • Tracks all assigned cases, organizes schedule to ensure all patients’ needs are met per their individual POC.
  • Meets agency productivity requirements.
  • Requests PTO in advance per agency protocol.
  • Communicates with the Intake Coordinator/ Clinical Supervisor regarding the coordination of the plan of care, need for overflow/weekend/after hour nurse assignment.
  • Ensures the availability of equipment/supplies and other necessary items necessary to support care plans; uses equipment/supplies per plan of care and documents per agency policy.
  • Provides instruction for other team members.

COMMUNICATION/CARE COORDINATION – Home Health

  • Provides updates for the primary physician when necessary and at least every sixty days.
  • Facilitates ongoing care discussions and team case conference discussion of the patient goals, progression, needs for ongoing care, and revises goals and/or interventions to enhance patient progress toward discharge.

COMMUNICATION/CARE COORDINATION – Hospice

  • Provides for IDG/IDT and primary physician, when necessary and every two weeks.
  • Participates in conferences or communications with IDT to obtain/receive treatment changes; and communicates new/changed orders to appropriate team members.40. Facilitates ongoing care discussions with IDG/IDT and team members regarding needs for ongoing care, revisions of interventions to achieve desired outcomes.

ADDITIONAL DUTIES

  • Participates in personal, professional growth and development. Attends all mandatory inservices; maintains current licensure. Independently seeks learning opportunities.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

POSITION QUALIFICATIONS

  • Graduate of an accredited school of nursing program.
  • Bachelor’s degree preferred.
  • One to two years of home health (preferred) or recent experience in an acute care/rehabilitation setting providing care for the adult patient.
  • Current licensure in the state(s) in which care is being provided. Current CPR certification
  • Valid driver license in one of the states in which care is provided, and dependable/available transportation and proof of current auto liability insurance.
  • Management experience not required. Responsible for supervising home health aides.6. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills, nursing skills per competency checklist.
  • Must be able to utilize good judgement, demonstrate patience and maintain a professional demeanor at all times.8. Demonstrate good verbal and written communications, and organizational skills.

Job Type: Full-time

Job Location:

  • Anchorage, AK

Required education:

  • Bachelor’s

Required experience:

  • Home Health Nursing: 2 years

Required licenses or certifications:

  • Registered Nurse (RN)
  • BLS

Click To Apply

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