RN Case Manager - Home Care
Full Time
Windsor, VT 05089
Posted
Job description
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Develops a plan of care under the direction of the patient’s physician and in collaboration with the patient, their family and/or the primary care givers upon admission. Periodically reviews the patient care plan and recertifies the patient care plan as appropriate.
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Coordinates the patient’s care plan through interdisciplinary communication and case conferences, as appropriate. Advises other disciplines of discharges in a timely manner.
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Provides ongoing assessment of the patient’s clinical, functional, and emotional status to identify problems and/or progress toward desired goals. Communicates significant changes to the patient’s physician and VNH colleagues as appropriate.
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Initiates and applies therapeutic clinical interventions using appropriate technique.
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Initiates referrals for interdisciplinary services when indicated in a complete and accurate manner. Obtains appropriate MD approval.
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Supervises ancillary personnel (HCA and Licensed Practical Nurses) and delegates responsibilities when required. Establishes a care plan for paraprofessional services and revises as needed according to agency policy.
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Completes and submits accurate and relevant clinical notes and other required documentation in a timely manner in accordance with expected agency standards, i.e., admission papers and OASIS; clinical notes; day sheets; status change; resumption of care; verbal orders/memos; payer source documentation, including management of authorizations; discharge.
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Completes all clinical documentation on the laptop and in the home when appropriate and in a timely fashion. Transmits all information twice a day.
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Demonstrates knowledge of Medicare regulations and delivers care in accordance with Medicare Condition of Participation (COP).
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Arranges to have needed supplies and equipment in the patient’s home upon assessment of need. Appropriately uses supplies and equipment. Seeks out education for any unfamiliar procedures/products.
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Manages visits to meet patient goals in a cost-effective manner.
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Teaches the patient and caregiver self-care techniques as appropriate. Provides medication, diet, and other instructions as ordered by the physician and utilizes opportunities for health counseling with patients and caregivers
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Identifies and communicates concerns regarding patient safety and/or environmental safety issues to the management staff.
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Accepts responsibility of assignment to perform a specialized procedure and/or see patients in other programs as needed such as, but not limited to, Hospice, etc.
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Participates in the agencies after hours call and weekend visit program in a responsible and willing fashion. Follows up on patient concerns appropriately.
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Participates in the agency’s orientation program as requested including precepting student nurses.
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Seeks opportunities for life-long learning (journals, outside educational programs, Home Care grand rounds, agency lecture opportunities, etc.)
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Maintains good rapport with all staff, patients, families and other members of the health care team. Maintains a positive attitude at all times both in the office and in the home.
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Meets or exceeds productivity measures established by the agency.
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Graduate of an accredited school of nursing
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Current licensure in the states of VT and NH
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Medical/Surgical nursing and/or home health Care experience
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Licensed RN in VT and NH
***** $5,000 Sign On Bonus Available*****
PURPOSE
Manages a case load of home care patients. Assesses, plans, implements, coordinates, and evaluates care for each patient, which includes but is not limited to: appropriate treatment intervention, evaluation of outcomes, and utilization of services to ensure that patient care needs are met. Supervises other Home Care staff as necessary. Works closely with other disciplines to ensure high quality patient care and outcomes.
KEY RESPONSIBILITIES
MINIMUM QUALIFICATIONS
REQUIRED LICENSE/CERTIFICATIONS/REGISTRATIONS SKILLS (Tracked at the department level)
Location: Visiting Nurse and Hospice for VT and NH · Home Health Blue
Schedule: Full Time, Days
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