Case Manager (RN) Home Health

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke HomeCare & Hospice

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

Duke Nursing Highlights:

• Duke University Health System is designated as a Magnet organization
• Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
• Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
• Duke University Health System has 6000 + registered nurses
• Qualityof Life: Living in the Triangle!
• Relocation Assistance (based on eligibility)

At Duke Home Health, you are able to meet patients where they are! By working as a home health nurse, you are able to help keep patients out of the hospital and in their homes where they are most comfortable. Duke HomeCare and Hospice provides innovative and thoughtful care by using an interdisciplinary team approach to achieve the best possible outcomes for patients, families and the communities for which they serve. In this role, you would have the opportunity to connect the patient with the right level of care at the right time.

Duke HomeCare and Hospice differs from other home health companies in many amazing ways. Please see a list of some of those reasons below:

1. No call or weekend requirements
2. Manageable territories
3. Commitment to safety for both patients and employees
4. Mileage reimbursement rate equal to the current federal rate
5. Extensive orientation of 20 weeks based on individual needs

Shifts: Monday-Friday- 8 hour days

JOB SUMMARY:

Performs professional nursing care for patients in a primary care setting (the home or alternate site setting) according to nursing practices, agency policies and regulations. Provide nursing services to patients and families in accordance with the scope of the RN as defined by the North Carolina Board of Nursing.

MAJOR JOB RESPONSIBILITIES:

1. Plan, provide, supervise and document professional nursing care utilizing the nursing process for patients in accordance with the NC nurse practice act, physician orders and established policies and procedures.  Uses professional nursing judgment to individualize the plan of care based on assessment of the patient’s baseline needs and response to care.
2. Utilize comprehensive assessment skills to plan priorities and to set realistic outcomes; collaborate with healthcare team in the evaluation and cost effectiveness of patient care.
3. Assess educational needs of patients/families concerning alterations in health, the disease process, and plan of care.
4. Develop and implement an effective discharge plan for patients to begin at the initiation of services.
5. Obtain or develop appropriate educational resources for patients/families; plan and implement appropriate educational interventions; evaluate effectiveness and outcomes of patient/family teaching.
6. Role model professional nursing through conduct, appearance, communication, mutual respect, ethical decision-making, critical thinking, and problem-solving skills.
7. Participate in weekly interdisciplinary team meetings and case conferences, as necessary, to assure appropriate care and service are provided to the patient.
8. Maintain up to date knowledge of Medicare/Medicaid/JCAHO standards thru inservices and workshop attendance.
9. Assesse the severity of patient symptoms, communicate to the physician and record significant findings, intervenes as appropriate.
10. Document care and services provided in accordance with DHCH Policy and Procedures and regulatory standards.
11. Complete documentation accurately, timely, concisely.
12. Medication reconciliation and education to prevent adverse events and readmission to hospital
13. Observe patient’s reactions to medications and reports significant incidents to the physicians.
14. Communicate regularly with team members, caregivers, and physicians.
15. Follow infection control standard precautions and uses personal protective equipment as required.
16. Delegate and supervise care given by NCA’s/LPN’s.
17. Develop plan of care for aides, assign care to aides based on the skills of the aide, the availability of the aide for patient care continuity, patient preference (when possible), and other considerations as determined by the patient’s care needs.
18. Identify personal learning needs and implements corrective action: assists in planning and conducting staff development programs to improve DHCC effectiveness.
19. Participate in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings.
20. Implement agency policy, procedures and objectives.
21. Work closely and collaboratively with agency billing staff to ensure accuracy of billing.
22. Maintain confidentiality of employee and patient information.
23. Exhibit an attitude which promotes harmony and goodwill in the workplace.
24. Display a clean, neat, professional appearance.
25. Participate in Performance Improvement Program.
26. Promote quality, comprehensive services through a team approach.
27. Perform other duties as assigned.

Home Health

• Case manage interdisciplinary team of clinicians caring for patients in the home.
• Complete required OASIS Comprehensive assessments at admission, recertification, Resumption of care and discharge.  This assessment determines patient reimbursement for Medicare and other episodic payors and also results in publicly reported patient outcomes and additional payment impacts related to value based purchasing
• Work with interdisciplinary team and patient providers to prevent re-hospitalization of the patient.
• Be aware of patient insurance requirements and assures authorization for all services have been obtained.
• Appropriate utilization of resources for patient including visit and supply utilization.

WORK ENVIRONMENT AND REQUIREMENTS:

Perform Patient care primarily in the patient’s residence or skilled nursing facility (>50%)

Travel to and from patient residence

PREFERRED QUALIFICATIONS

Education and Formal Training

• Associate Degree or Diploma, Nursing required
• Registered Nurses are not required but encouraged to enroll in a DUHS approved BSN program after completing two years of service of their start date.

Licensures, Certifications

• Must have a current RN license in NC or compact RN licensure from participating state. 
• Current State of North Carolina Cardio-Pulmonary Resuscitation Certificate (CPR) (American Heart Association only) May renew during orientation
• Valid driver's license and current automobile insurance coverage.

Professional Work Experience 

• 1-2 years of med-surgical, critical care or home health/hospice/infusion preferred
• Valid driver’s license and current automobile insurance coverage
• Prior experience in Home Health, Hospice or Infusion preferred
• Prior OASIS and PDGM experience preferred for home health

Knowledge, Skills & Abilities

• Working knowledge of Medicare and Medicaid regulations, including JCAHO and DFS standards, ICD-9 Coding.
• Knowledge of scope of the registered nurse, licensed practical nurse and NCA
• Knowledge of and appropriate application of the nursing process
• Ability to assess nursing needs of acute and chronically ill patients and their families
• Ability to independently seek out resources and work collaboratively
• Ability to establish and maintain effective working relationships
• Ability to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership and others
• Ability to teach patients and families in accordance with the nursing plan of care
• Ability to use sensory and cognitive functions to process and prioritize information, treatment, and follow-up
• Ability to use fine motor skills
• Ability to record activities, document assessments, plan of care, interventions, evaluation and re-evaluation of patient status
• Ability to use computer and learn new software programs and technology
• Able to document and communicate pertinent information using computer and/or paper documentation tools
• Knowledge in wound identification and treatments, infusion and other advanced nursing skills
• Critical thinking skills and organization skills
• Working knowledge of infection control procedures and safety precautions
• Strong computer skills including MS Outlook, Word, Excel, preferred
• Excellent rapport, understanding, and communication with the patients and their family members
• Ability to work autonomously and independently in varying environments.
• Able to withstand driving long distances, stooping, bending, lifting 20 plus pounds, and climb stairs