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Health at Home Registered Nurse Case Manager

Job Summary Manages the plan of care and services of assigned patients Coordinates all disciplines involved in the assigned patients plan of care Partners with others to effect change and produce positive patient outcomes Provides direct care and health counseling and teaching to agency patients Participates in the Agency's Community Wellness Program Performs on-call and extended hours activities to meet the needs of the agency as assigned Performs all duties in compliance with applicable federal and state regulations and Agency policies and procedures Provides exemplary customer service to all customer contacts Performs all other duties that management may determine necessary Reports to the Clinical Manager Qualifications Minimum Education and Experience The Nurse Case Manager will have one of the following: (1) B.S. in Nursing; (2) Associates Degree in nursing; (3) RN diploma from an approved school of nursing. The Nurse Case Manager must be a registered nurse with an active license to practice nursing in the State of Connecticut who has at least one (1) years' nursing experience in an acute/sub-acute or home care setting. Other Qualifications Proof of completion of an Infusion Therapy Education Program preferred Current certification in Cardiopulmonary Resuscitation from American Heart Association or American Red Cross Must possess a valid driver's license and personal vehicle. Physical, mental and sensory abilities sufficient to meet performance criteria with or without assistive devices. Performance Criteria The Nurse Case Manager will possess the following skills and attributes to be responsible for providing direct care, health counseling and teaching to agency patients. Utilizes sound clinical judgment and age appropriate techniques in the assessment of patients' physical and psychosocial needs for home care. Develops and collaborates in the implementation of the home health care plan under the direction of a physician or dentist and documents the plan of care and any revisions for each patient. Documents assessments and care provided, thoroughly and accurately. Completes and submits required documentation in accordance with agency policy. Delegates care activities appropriately to licensed practical nurses and home health aides. Orients and supervises licensed practical nurses and home health aides in the plan of care in accordance with agency policy and federal and state regulations. Implements the physician ordered plan of care using available resources. Obtains physician or dentist orders for all changes in treatment and medical supplies. Obtains insurance authorization as needed for reimbursement. The Nurse Case Manager partners with others to effect change and produce positive patient outcomes Orients and supervises professional and paraprofessional personnel providing patient services. Communicates information regarding each patient's health status and plan of care among all relevant care providers, including the home health aide and the physician or dentist. Information may include but not be limited to: Patient condition, response to interventions and teaching, changes in plan of care and discharge planning. Reports abnormal findings or additional needs to the physician or dentist in charge of patient's care. Makes referrals to other disciplines when indicated and ordered. Provides supportive and restorative nursing care and patient counseling and teaching in accordance with agency policy and procedure and accepted standards of practice. Adheres to infection control and exposure prevention practices as outlined by agency policies and procedures. The Nurse Case Manager manages the plan of care and services of assigned patients Ensures that there is coordinated and effective sharing of information amongst and between all disciplines, with contracted service providers and other patient care providers as identified. Continually evaluates the patient's plan of care for skilled and home health aide services and makes revisions as necessary. Collaborates with the interprofessional team and community resources and maintains communication related to the patient's response to the plan of care. Regularly evaluates patient progress toward goals and facilitates discharge planning collaboratively with the patient, family and the physician or dentist. Documents case conferences with other disciplines/clinical team members, clinical manager, physician or dentist, etc. in accordance with agency policies. The Nurse Case Manager provides exemplary customer service to all customer contacts. Treats patients, family members, and caregivers respectfully and courteously. Treats colleagues with respect, trust and dignity. Precepts colleagues, including those new to home health practices, and participates in the orientation process when assigned. Participates in the education of nursing students and serves as role model. Promotes and educates the public regarding agency services and agency specialty programs. Participates in the Agency's Community Wellness Program that may include but are not limited to blood pressure, diabetic screenings, health counseling, education and administration of vaccines to community dwelling adults The Nurse Case Manager contributes to the agency's Quality Improvement (QI) Program. Participates in the agency 's QI committee activities to enhance home health policies, standards and practices Identifies areas for improvement within agency processes as well as personal/professional learning needs. Regularly attends staff meetings, inservices or outside seminars to enhance practice and knowledge. Meets mandatory inservice and competency requirements as determined by the agency. Accountability/Responsibility Can be relied upon to meet requirements of job description, with a minimum of supervision Communicates schedule changes and need for assistance to manager or appropriate person Is prompt and attends meetings and programs as expected Organization/Productivity Demonstrates an ability to perform job responsibilities in an organized, efficient manner Prioritizes needs and meets productivity standards for the department Adaptability Demonstrates an ability to understand and carry out instructions Adapts to changing conditions during the work day and in the industry Remains focused and responds appropriately when under pressure Documentation Ability to complete and submit job related/required reports in an accurate, clear, concise and timely manner, assuring that content meets any federal, state, local and agency requirements Professional Integrity Demonstrates integrity and sound decision making in all issues related to job Adheres to standard of confidentiality, discussing patient and agency information only with appropriate personnel in the proper setting Promotes a positive image of the agency at all times Attendance Demonstrates faithfulness in coming to work in accordance with assigned work schedule Adheres to the Agency's Attendance Policy Teamwork/Commitment Functions with an understanding of individual performance and its impact on co-workers Works cooperatively and assists department and agency co-workers as needed Volunteers for projects/committees to achieve department and/or agency goals Interpersonal Skills/Communication Demonstrates an ability to effectively express self, orally and written Shows respect and courtesy in interactions Seeks clarification from appropriate source if communication is not clearly understood Displays a positive attitude and is resolution oriented Ambition/Motivation Demonstrates ability to take initiative and to follow through on responsibilities and projects Presents ideas effectively and encourages participation by others Delegates responsibility appropriately and offers support and guidance as necessary Creativity Demonstrates innovative ideas and suggests positive approaches to problem solving Recommends plan for implementation Personal Appearance Adheres to Human Resources Dress and Footwear Policy