RN Case Manager
U.S. Medical Management (USMM) is an affiliate of a leading Fortune 100 company. A national organization built on a continuum of care with premier healthcare providers, clinicians and patient focused individuals working together. Our Mission Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services Visiting Physicians Association, Pinnacle Senior Care, Grace Hospice, Comfort Hospice, Home DME & our In Home Health Assessments (IHA).
Our Values of Integrity, Respect, Teamwork & Excellence are leading us to a better tomorrow for patient care. Our Purposes Centered on We are Unified in our Work through our Continuum of Services We can Find Comfort that We are Making a Difference for our Patients & We make a Broader Positive Impact on Society, allows USMM to be poised for a phenomenal future.
We are seeking candidates who desire the experience of delivering quality & compassionate healthcare within proven care models with patients at the forefront of everything we do.
Under the general supervision of the Clinical Supervisor/Clinical Manager, the RN - Case Manager provides intermittent skilled nursing services; communicates the patients progress with other disciplines and directs, supervises and instructs non-professional home health aide staff in the provision of personal care to the patient.
Essential Duties and Responsibilities
- Under the Physicians order, admits patients eligible for home care services within 24-48 hours
- Assessesand evaluates patient needs/problems, identifies mutually agreed upon goals with patients
- Reports patient status and need for other disciplines to agency Clinical Supervisor and referring Physician
- Reports to assigned follow-up Clinician as indicated
- Develops patient care plan that specifically addresses identified patient problems; patient problems and goals
- Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or at recertification
- Completesadmission paperwork and patient care plan submitted to Clinical Supervisor per agency policy following the admission including completed and signed admission checklist
- Provides intermittent Skilled Nursing services including assessment, evaluation, procedures, teaching, and training activities as outlined in the patient Plan of Care
- Provides Skilled Nursing visits according to visit schedule and notifies agency of need to alter schedule in any way
- Reports significant findings to patients Physician and Clinical Supervisor as they occur
- Submits completed skilled nursing visit notes; communication notes and home health aide supervisory notes per agency policy on designated days as requested by Clinical Supervisor
- Submits change orders per agency policy
- Performs all OASIS time point assessment per Medicare Criteria and submits recertification paperwork per agency policy and procedure
- Maintains open lines of communications to all members of the continuum of care team.
- Supervises Home Health Aide and license and documents per Medicare criteria and per agency policy and procedure
- Acts as a preceptor in the orientation of new nursing staff as requested
- Attends staff meetings, team conferences and educational in-services per agency requirements
- Participates in Process Improvement (PI) program by assisting with collection of data and serves on PI team upon request
- Participates in discharge planning process Medicare Criteria and agency policy and procedure
- Follows agency policies and procedures
- Performs these and all other duties as assigned by the Administrator
- Able to lift 40 pounds from floor to shoulder
- Repetitive walking, standing, sitting, bending, and use of hands
- Able to drive a car 2-4 hours per day
REQUIRED Knowledge, Skills, and Experience
- Current unencumbered State Professional Nurse License
- Automobile to be used for work, current drivers license, good driving record, and proof of insurance
- The ability to make sound professional clinical judgment
- The ability to assess and document patient needs and formulate individualized patient care plans to meet those needs
- Proficient clinical skills
- Excellent verbal and written communication skills
- Proficiency in personal computer use, including e-mail, clinical, word processing, spreadsheet, and presentation software
Preferred Knowledge, Skills, and Experience
- One year of experience as a home care professional nurse and is competent in performing home care comprehensive assessment
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