RN Home Health Full-time
PACE Southeast Michigan

Lead RN Case Manager

PACE Southeast Michigan Detroit, MI, US

SUMMARY:

The Registered Nurse Case Manager (RNCM) of the PACE Southeast Michigan (PACE SEMI) utilizes a systematic approach to nursing practice which incorporates all aspects of the nursing process including, assessment, planning, implementation and evaluation of frail elders with complex needs.  The RN demonstrates a direct relationship between nursing interventions and participant outcomes, demonstrates clinical competence and engages in effective patient teaching in areas of prevention as well as treatment.  The RN effectively leads or directs licensed and non-professional nursing staff in the coordinated delivery of care to participants of the PACE Southeast Michigan program.  The focus of care is one that enhances functional capacity, encouraging autonomy in all aspects of care, and assures coordination of all nursing care.

SPECIFIC DUTIES AND FUNCTIONS:

  • The RNCM assesses participants’ needs and plans for appropriate nursing care upon the Initial Intake Assessment as well as upon routine Re-Evaluation Assessments.
  • The RNCM works and collaborates with the participant and the family, as well as all members of the multidisciplinary Team in developing the participant’s plan of care. 
  • The RNCM maximizes the participant’s functional capacity by encouraging autonomy in all aspects of care.
  • The RNCM teaches, supervises and counsels the participant, or caregiver regarding nursing care needs and other related problems.  The RN utilizes adult learning principles when planning for and implementing educational information to the participants, caregivers or family members.
  • The RNCM initiates preventative and rehabilitative procedures or programs as appropriate for the participants’ care and safety.
  • The RNCM administers medications and treatments, as ordered by the physician/NP, and monitors the participant’s response.  The RN notifies the appropriate medical personnel of changes in the participant’s status.
  • The RNCM demonstrates knowledge of the medications he/she administers and instructs the participant/family in safe administration of medication in the home.  Assesses for and encourages compliance with medication regimen.
  • The RNCM recognizes and understands the significance of abnormal test results and utilizes critical thinking skills when gathering participant data, planning for, and implementing care.
  • The RNCM provides safe total patient care to participants with complex health problems with a focus on the individual participant and the family.
  • The RNCM maintains all standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration.
  • The RNCM leads and monitors licensed and other professional and non-professional staff in the delivery of nursing care to the participant in the home.  The RN is responsible for monthly supervision and subsequent documentation of home health aide services provided in the participant’s home.
  • The RNCM evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information among other members of the Multidisciplinary Team. 
  • The RNCM collaborates with the Interdisciplinary Team to revise the plan of care based on changes in the participants’ physical or psychosocial status, and initiates actions that are consistent with the changes in status.
  • The RNCN participates with patients, families and members of the Interdisciplinary Team to evaluate/measure the individual and group response to nursing care and teaching interventions and documents the outcomes of the problems identified at every scheduled review.
  • The RNCM maintains accurate and timely records of participant’s functional /health status, progress toward care plan outcomes, revisions to care plans, care given, etc.  All charting and documentation is performed in accordance with CSI policies/procedures.  The RNCM participates in the collection and documentation of Data PACE information. 
  • The RNCM advocates to others on behalf of the participant, and demonstrates accountability in resolving participant concerns or issues.
  • The RNCM understands, complies with and promotes the Participant Bill of Rights and assesses and works toward achieving high levels of participant satisfaction.
  • The RNCM may provide after hours on-call medical assistance on a rotating basis, via phone triage or after hours home visits to participants as needed.
  • Schedule requires a rotating on call shift.

KNOWLEDGE, SKILLS AND ABILITIES:

  • Must be a Registered Nurse with current Michigan licensure, BSN preferred. 
  • The RNCM participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training.
  • The RNCM assumes responsibility for self-development through continuing education, utilizing resources within the health care system or elsewhere; the RN promotes professional behavior and growth by serving as a role model within the health team. 
  • The RNCM must possess a current State of Michigan driver’s license and maintain an acceptable driving record.
  • The RNCM has the ability to establish and maintain interpersonal and interdepartmental relationships.
  • The RNCM has the ability to apply principles of adult learning in planning and implementing educational activities.
  • The RNCM has the ability to lead and direct other licensed and non-professional nursing staff in the delivery of care.
  • The RNCM participates in and/or facilitates Quality Assurance projects resulting from data results.
  • The RNCM assists with the implementation of nursing research studies. 
  • The RNCM reviews current periodical literature relevant to the general practice of nursing as well as information pertaining to the PACE model of care.
  • The RNCM ensures adherence to departmental and external standards in the provision of quality focused care by attendance at professional meetings/committees and review of national standards of practice.
  • Must meet a standardized set of competencies (approved by CMS) before working independently. 
  • Must have one (1) year of experience with a frail or elderly population.

WORKING CONDITIONS:

  • Works in the participant’s home which is an uncontrolled environment.  May be exposed to potentially infectious materials, blood-borne disease pathogens, and hazardous waste.  Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact
  • Driving is required within PACE SEMI catchment area, with possible exposure to extreme temperatures, including heat and cold.  Must have reliable transportation available on a daily basis.
  • Frequent walking, bending, lifting of forty (40) pounds or more may be needed in the performance of duties.

Share this job

Share to FB Share to LinkedIn Share to Twitter

Related Jobs

RN Home Health Per Diem
Freedom At Home

Home Health RN Case Manager

Freedom At Home Rochester, MI
Home Health Registered (RN) - Per Diem *Fantastic pay based on points per visit type in addition to paid mileage!!! Freedom at Home is a Combat and Service Disabled Veteran owned and operated Small Business that offers Skilled Home Care Services. Welcome to Freedom at Home! Freedom at home is looking to hire compassionate, dedicated, and hard working clinicians. Clinicians who value their work and take pride in what they do. Clinicians who want to work for a company that values them and their input. Caring for patients is more than just a job to us and we want clinicians who feel the same way. We are looking to be change agents in this industry. We will strive to be a 5 star agency and maintain that. We hold ourselves to the highest standard and we welcome anyone to join our team who does the same. Clinicians on our team are highly valued and highly rewarded. We work as a team to provide the highest quality of care and outcomes. Are you a 5 star clinician? Are you tired of being under paid and under valued? Are you frustrated with working with others who don't value work ethic, compassion, respect, and dignity? Do you think healthcare can do better? If so then you may be a great fit for our Freedom team! JOB SUMMARY A professional who provides professional nursing services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates patients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Director of Nursing. QUALIFICATIONS Graduate of an approved professional nursing program (RN) Currently, licensed “in good standing” in MI Minimum of one (1) year of experience as a professional nurse, preferably in home care. Must have a criminal background check. Must have current CPR certification. RESPONSIBILITIES/ESSENTIAL FUNCTIONS Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures. Prepares & submits timely, clinical and progress notes. Oversees coordination of patient services. Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation. Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs. Determines medical necessity for other services. Regularly re-evaluates the patient’s nursing needs. Evaluates the patient’s ADL and iADL abilities and need for home health aide. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period. Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs. Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services. Effectively communicates ongoing with patient and family progression/changes in POC. Effectively communicates with Supervisor/Nursing Director/other disciplines in the case. Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities. Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely. Coordinates Community Services for the patient to assist in safe home care needs. Participates in the Performance Improvement Committee process. Performs timely clinical record reviews (CRR) per Agency policy in collaboration with the Nursing Supervisor. Participates in ongoing staff meetings/in-services. Participates in the growth of office by being a willing preceptor for same discipline employees. Participates in the planning, operation and evaluation of the nursing services of the organization. Maintains professional licensure per state requirements. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned. SPECIAL EQUIPMENT TO BE OPERATED Vehicle to do routine patient visits, possible transfer/lifting devices, medical supplies WORK ENVIRONMENT Indoors, performing patient care assessment/tasks in the patient’s residence Travel to patient residences/meetings; will require transportation to get to various work sites Possible exposure to communicable diseases FUNCTIONAL ABILITIES Able to access patient’s homes that may not be handicap accessible. Able to hear, speak, understand and communicate effectively in English. PHYSICAL REQUIREMENTS On a daily basis: walking, standing, sitting, reaching, use of telephone, use of computers & other office equipment, lifting/transferring 150 lbs or greater, bending, stooping, climbing stairs.
RN Home Health Per Diem
Freedom At Home

RN Home Health Case Manager

Freedom At Home Rochester, MI
Home Health Registered (RN) - Per Diem Hiring for the following counties: Ingham, Jackson Open to part time, per diem and full time! *Fantastic pay with option for salaried and per point, in addition to paid mileage!!! Freedom at Home is a Combat and Service Disabled Veteran owned and operated Small Business that offers Skilled Home Care Services. Welcome to Freedom at Home! Freedom at home is looking to hire compassionate, dedicated, and hard working clinicians. Clinicians who value their work and take pride in what they do. Clinicians who want to work for a company that values them and their input. Caring for patients is more than just a job to us and we want clinicians who feel the same way. We are looking to be change agents in this industry. We will strive to be a 5 star agency and maintain that. We hold ourselves to the highest standard and we welcome anyone to join our team who does the same. Clinicians on our team are highly valued and highly rewarded. We work as a team to provide the highest quality of care and outcomes. Are you a 5 star clinician? Are you tired of being under paid and under valued? Are you frustrated with working with others who don't value work ethic, compassion, respect, and dignity? Do you think healthcare can do better? If so then you may be a great fit for our Freedom team! JOB SUMMARY A professional who provides professional nursing services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates patients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Director of Nursing. QUALIFICATIONS Graduate of an approved professional nursing program (RN) Currently, licensed “in good standing” in MI Minimum of one (1) year of experience as a professional nurse, preferably in home care. Must have a criminal background check. Must have current CPR certification. RESPONSIBILITIES/ESSENTIAL FUNCTIONS Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures. Prepares & submits timely, clinical and progress notes. Oversees coordination of patient services. Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation. Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs. Determines medical necessity for other services. Regularly re-evaluates the patient’s nursing needs. Evaluates the patient’s ADL and iADL abilities and need for home health aide. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period. Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs. Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services. Effectively communicates ongoing with patient and family progression/changes in POC. Effectively communicates with Supervisor/Nursing Director/other disciplines in the case. Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities. Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely. Coordinates Community Services for the patient to assist in safe home care needs. Participates in the Performance Improvement Committee process. Performs timely clinical record reviews (CRR) per Agency policy in collaboration with the Nursing Supervisor. Participates in ongoing staff meetings/in-services. Participates in the growth of office by being a willing preceptor for same discipline employees. Participates in the planning, operation and evaluation of the nursing services of the organization. Maintains professional licensure per state requirements. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned. SPECIAL EQUIPMENT TO BE OPERATED Vehicle to do routine patient visits, possible transfer/lifting devices, medical supplies WORK ENVIRONMENT Indoors, performing patient care assessment/tasks in the patient’s residence Travel to patient residences/meetings; will require transportation to get to various work sites Possible exposure to communicable diseases FUNCTIONAL ABILITIES Able to access patient’s homes that may not be handicap accessible. Able to hear, speak, understand and communicate effectively in English. PHYSICAL REQUIREMENTS On a daily basis: walking, standing, sitting, reaching, use of telephone, use of computers & other office equipment, lifting/transferring 150 lbs or greater, bending, stooping, climbing stairs.
RN Home Health Per Diem
Freedom At Home

Home Health RN Case Manager

Freedom At Home Rochester, MI
Home Health Registered (RN) - Per Diem *Fantastic pay based on points per visit type in addition to paid mileage!!! Freedom at Home is a Combat and Service Disabled Veteran owned and operated Small Business that offers Skilled Home Care Services. Welcome to Freedom at Home! Freedom at home is looking to hire compassionate, dedicated, and hard working clinicians. Clinicians who value their work and take pride in what they do. Clinicians who want to work for a company that values them and their input. Caring for patients is more than just a job to us and we want clinicians who feel the same way. We are looking to be change agents in this industry. We will strive to be a 5 star agency and maintain that. We hold ourselves to the highest standard and we welcome anyone to join our team who does the same. Clinicians on our team are highly valued and highly rewarded. We work as a team to provide the highest quality of care and outcomes. Are you a 5 star clinician? Are you tired of being under paid and under valued? Are you frustrated with working with others who don't value work ethic, compassion, respect, and dignity? Do you think healthcare can do better? If so then you may be a great fit for our Freedom team! JOB SUMMARY A professional who provides professional nursing services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates patients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Director of Nursing. QUALIFICATIONS Graduate of an approved professional nursing program (RN) Currently, licensed “in good standing” in MI Minimum of one (1) year of experience as a professional nurse, preferably in home care. Must have a criminal background check. Must have current CPR certification. RESPONSIBILITIES/ESSENTIAL FUNCTIONS Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures. Prepares & submits timely, clinical and progress notes. Oversees coordination of patient services. Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation. Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs. Determines medical necessity for other services. Regularly re-evaluates the patient’s nursing needs. Evaluates the patient’s ADL and iADL abilities and need for home health aide. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period. Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs. Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services. Effectively communicates ongoing with patient and family progression/changes in POC. Effectively communicates with Supervisor/Nursing Director/other disciplines in the case. Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities. Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely. Coordinates Community Services for the patient to assist in safe home care needs. Participates in the Performance Improvement Committee process. Performs timely clinical record reviews (CRR) per Agency policy in collaboration with the Nursing Supervisor. Participates in ongoing staff meetings/in-services. Participates in the growth of office by being a willing preceptor for same discipline employees. Participates in the planning, operation and evaluation of the nursing services of the organization. Maintains professional licensure per state requirements. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned. SPECIAL EQUIPMENT TO BE OPERATED Vehicle to do routine patient visits, possible transfer/lifting devices, medical supplies WORK ENVIRONMENT Indoors, performing patient care assessment/tasks in the patient’s residence Travel to patient residences/meetings; will require transportation to get to various work sites Possible exposure to communicable diseases FUNCTIONAL ABILITIES Able to access patient’s homes that may not be handicap accessible. Able to hear, speak, understand and communicate effectively in English. PHYSICAL REQUIREMENTS On a daily basis: walking, standing, sitting, reaching, use of telephone, use of computers & other office equipment, lifting/transferring 150 lbs or greater, bending, stooping, climbing stairs.
RN Home Health Per Diem
Freedom At Home

Home Health RN Case Manager

Freedom At Home Rochester, MI
Home Health Registered (RN) - Per Diem *Fantastic pay based on points per visit type in addition to paid mileage!!! Freedom at Home is a Combat and Service Disabled Veteran owned and operated Small Business that offers Skilled Home Care Services. Welcome to Freedom at Home! Freedom at home is looking to hire compassionate, dedicated, and hard working clinicians. Clinicians who value their work and take pride in what they do. Clinicians who want to work for a company that values them and their input. Caring for patients is more than just a job to us and we want clinicians who feel the same way. We are looking to be change agents in this industry. We will strive to be a 5 star agency and maintain that. We hold ourselves to the highest standard and we welcome anyone to join our team who does the same. Clinicians on our team are highly valued and highly rewarded. We work as a team to provide the highest quality of care and outcomes. Are you a 5 star clinician? Are you tired of being under paid and under valued? Are you frustrated with working with others who don't value work ethic, compassion, respect, and dignity? Do you think healthcare can do better? If so then you may be a great fit for our Freedom team! JOB SUMMARY A professional who provides professional nursing services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates patients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Director of Nursing. QUALIFICATIONS Graduate of an approved professional nursing program (RN) Currently, licensed “in good standing” in MI Minimum of one (1) year of experience as a professional nurse, preferably in home care. Must have a criminal background check. Must have current CPR certification. RESPONSIBILITIES/ESSENTIAL FUNCTIONS Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures. Prepares & submits timely, clinical and progress notes. Oversees coordination of patient services. Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation. Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs. Determines medical necessity for other services. Regularly re-evaluates the patient’s nursing needs. Evaluates the patient’s ADL and iADL abilities and need for home health aide. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period. Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs. Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services. Effectively communicates ongoing with patient and family progression/changes in POC. Effectively communicates with Supervisor/Nursing Director/other disciplines in the case. Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities. Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely. Coordinates Community Services for the patient to assist in safe home care needs. Participates in the Performance Improvement Committee process. Performs timely clinical record reviews (CRR) per Agency policy in collaboration with the Nursing Supervisor. Participates in ongoing staff meetings/in-services. Participates in the growth of office by being a willing preceptor for same discipline employees. Participates in the planning, operation and evaluation of the nursing services of the organization. Maintains professional licensure per state requirements. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned. SPECIAL EQUIPMENT TO BE OPERATED Vehicle to do routine patient visits, possible transfer/lifting devices, medical supplies WORK ENVIRONMENT Indoors, performing patient care assessment/tasks in the patient’s residence Travel to patient residences/meetings; will require transportation to get to various work sites Possible exposure to communicable diseases FUNCTIONAL ABILITIES Able to access patient’s homes that may not be handicap accessible. Able to hear, speak, understand and communicate effectively in English. PHYSICAL REQUIREMENTS On a daily basis: walking, standing, sitting, reaching, use of telephone, use of computers & other office equipment, lifting/transferring 150 lbs or greater, bending, stooping, climbing stairs.
RN Home Health Per Diem
Freedom At Home

Home Health RN Case Manager

Freedom At Home Rochester, MI
Home Health Registered (RN) - Per Diem *Fantastic pay based on points per visit type in addition to paid mileage!!! Freedom at Home is a Combat and Service Disabled Veteran owned and operated Small Business that offers Skilled Home Care Services. Welcome to Freedom at Home! Freedom at home is looking to hire compassionate, dedicated, and hard working clinicians. Clinicians who value their work and take pride in what they do. Clinicians who want to work for a company that values them and their input. Caring for patients is more than just a job to us and we want clinicians who feel the same way. We are looking to be change agents in this industry. We will strive to be a 5 star agency and maintain that. We hold ourselves to the highest standard and we welcome anyone to join our team who does the same. Clinicians on our team are highly valued and highly rewarded. We work as a team to provide the highest quality of care and outcomes. Are you a 5 star clinician? Are you tired of being under paid and under valued? Are you frustrated with working with others who don't value work ethic, compassion, respect, and dignity? Do you think healthcare can do better? If so then you may be a great fit for our Freedom team! JOB SUMMARY A professional who provides professional nursing services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates patients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Director of Nursing. QUALIFICATIONS Graduate of an approved professional nursing program (RN) Currently, licensed “in good standing” in MI Minimum of one (1) year of experience as a professional nurse, preferably in home care. Must have a criminal background check. Must have current CPR certification. RESPONSIBILITIES/ESSENTIAL FUNCTIONS Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures. Prepares & submits timely, clinical and progress notes. Oversees coordination of patient services. Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation. Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs. Determines medical necessity for other services. Regularly re-evaluates the patient’s nursing needs. Evaluates the patient’s ADL and iADL abilities and need for home health aide. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period. Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs. Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services. Effectively communicates ongoing with patient and family progression/changes in POC. Effectively communicates with Supervisor/Nursing Director/other disciplines in the case. Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities. Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely. Coordinates Community Services for the patient to assist in safe home care needs. Participates in the Performance Improvement Committee process. Performs timely clinical record reviews (CRR) per Agency policy in collaboration with the Nursing Supervisor. Participates in ongoing staff meetings/in-services. Participates in the growth of office by being a willing preceptor for same discipline employees. Participates in the planning, operation and evaluation of the nursing services of the organization. Maintains professional licensure per state requirements. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned. SPECIAL EQUIPMENT TO BE OPERATED Vehicle to do routine patient visits, possible transfer/lifting devices, medical supplies WORK ENVIRONMENT Indoors, performing patient care assessment/tasks in the patient’s residence Travel to patient residences/meetings; will require transportation to get to various work sites Possible exposure to communicable diseases FUNCTIONAL ABILITIES Able to access patient’s homes that may not be handicap accessible. Able to hear, speak, understand and communicate effectively in English. PHYSICAL REQUIREMENTS On a daily basis: walking, standing, sitting, reaching, use of telephone, use of computers & other office equipment, lifting/transferring 150 lbs or greater, bending, stooping, climbing stairs.