The LHCSA RN Case Manager is responsible for managing each patients care as efficiently and cost effectively as possible to achieve positive patient outcomes regardless of payer. The Case Manager is responsible for the overall plan of care and the outcome of that care, including care delivered by other staff (LPN, HHA, PCA) who must be directed and supervised by the LHCSA RN.
Overall responsibilities include providing and coordinating quality patient care while maintaining a case load/productivity as assigned by direct supervisor. Accurate and timely documentation supporting care provided and/or needs of the patient.
Conduct admission assessments and determine if a safe plan of care can be administered on the admission visit. Case manage primarily aide related services according to regulatory guidelines. Includes but is not limited to obtaining a medical
history, particularly as it relates to the present condition, from the patient and/or family member(s) when applicable.
Conducting a physical examination of the patient including vital signs, physical assessment, mental status, appetite and type of diet, assessment of activity of daily living, and advanced directives.
Evaluating the patients support system(s) and needs as it relates to health teaching.
Case conferencing according to established schedule
Evaluating the patients physical environment to determine needs as it relates to durable medical equipment and physical support required to assist in activities of daily living.
Evaluating the need for home health aide/personal care assistant support including time of day, frequency of visits and length of time required to complete the plan of care.
Meeting regulatory requirements and having a comprehensive understanding of various insurances.
Providing annual administrative evaluations for aides assigned to you
Practicing according to best practice standards and regulatory nursing standards.
Maintaining 12 CEUs as it relates to licensed home care & nursing services.
Identifying potential Skilled nursing services, treatments and preventive procedures and making referrals to the CHHA and/or Health Home.
Observing signs and symptoms as it relates to the holistic plan of care and report change in condition to the physician per regulatory guidelines.
Maintain relationships and clear lines of communication with MLTC case managers and other members of the care team.
Teaching, supervision and counseling the patient, family and caregivers regarding the plan of care. Oversee the care given by home health aides and personal care aides.
Communicate effectively with aides, provide mentoring & positive feedback through phone conversations, and visits
Oversee clinical skills of aides assigned to you, provide training
Communicate with aide preceptor regarding skills, possible support needed in field
Mentor new hires with consistent oversight
Supervising and evaluating the care given to the patient
Documents according to standards of nursing practice
Demonstrates competencies as it relates to information /technology
Document those services rendered to the patient, changes noted in the patients condition and/or family and home situation; Revise the plan of care as needed to ensure holistic needs are met
Contact the primary physician and/or notify the clinical supervisor per regulatory guidelines.
Establish and maintain relationships with community partners
Prepare and present informational educational sessions to the community
Minimum of two (2) years experience in home care.
Willing to be NHTD trained and PRI/UAS certified.
Bachelors Degree of Nursing required.
EOE Minorities / Females / Protected Veterans / Disabled
Associated topics: business development, case manager, development manager, liaison, manage, plan, project, program development, program management, project management