RN Case Manager Care at Home
Full Time Benefits
The RN Case Manager uses clinical nursing knowledge, physical assessment, teaching and procedural skills to deliver safe, high quality, high experience patient care in the patient’s place of residence. The RN Case Manager develops, delivers, and oversees the Care at Home plan of care under the direction of the patients’ Primary Care Provider (PCP), in collaboration with the Care Coordination Team, and, as applicable, under the direction of the Care at Home Provider. The RN Case Manager ensures appropriate interdisciplinary involvement to optimize the best outcome for each patient. The RN Case Manager is responsible for case managing the patients’ plan of care supporting safe, high quality care resulting in improved economic outcomes and exceptional patient experience.
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Essential functions are the duties and responsibilities that are essential to the position (not a task list). o not include if less than 5% of work time is spent on this duty. Be specific without giving explicit instructions on how to perform the task. Do not include duties that are to be performed in the future. Duties should be action oriented and avoid vague or general statements.
% of Time
Clinical Excellence/Patient Care
· Assesses the needs of patients and families, providing appropriate teaching and making the necessary referrals to provide continuity of care.
· Integrates and coordinates the care of the at-risk population across the healthcare continuum.
· Develops an individual plan of care using a collaborative approach with the patient/family and health care team.
· Ensures quality and safe delivery of services to patients according to care plan. Uses equipment and supplies safely, effectively, and efficiently.
· Promptly completes documentation to assure an accurate legal record of patient’s care and time and travel entries.
· Communicates clinical status and plans clearly, succinctly and accurately to interdisciplinary care team, administrative support team, leaders, and physicians.
· Delivers high quality care utilizing the nursing process while demonstrating knowledge and clinical skills of the specialty required on assigned unit in accordance with established policies, procedures and standards of care.
· Utilizes holistic approach (considering biopsychosocial, spiritual, educational, safety, and related criteria) appropriate to the age of the patients and families served in the assigned service area.
· Serves as a patient advocate, educator and as central source of communication for the patient, their support systems, and referral sources.
· Conferences with clinical management, physician and interdisciplinary team in order to provide high quality, cost effective care.
· Care is outcome-oriented, reflects measurable progress and goals toward discharge.
· Facilitates advance care planning discussions to ensure appropriate care coordination and high-quality care based on patient’s long-term goals of care.
· Delegates and provides direction for other healthcare providers and hold them accountable for their involvement in the plan of care.
· Utilizes critical thinking in making independent judgments, and maintains responsibility and accountability for the knowledge of conditions of assigned patients.
· Identifies risk for acute hospitalization and proactively prevents adverse events.
· Reviews multidisciplinary care provision, conducts own clinical review and participates in peer audit, as applicable.
· Assists in the promotion of services and products.
· Performs “on-call” duties and weekend/after hour visits on a rotational basis as assigned.
· Performs other duties as requested by supervising leader to facilitate smooth and effective operations of the organization.
Development & Patient Education
· Continues professional development and involvement in professional activities that enhance nursing practice by sharing knowledge through networking and research.
· Assess and chooses teaching strategies appropriate to the patient’s and their families’ age specific needs, culture, gender, readiness to learn and level of comprehension.
· Provides patient, family, and/or caregiver education and information pertinent to diagnosis and safety issues.
· Consults appropriate resources to provide specialized education.
· Demonstrates knowledge that patient and workplace safety is a priority by preventing errors, accidents and infections and reporting potential or actual concerns immediately.
Basic UPH Performance Criteria
· Demonstrates the UPaH / UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
· Demonstrates ability to meet business needs of department with regular, reliable attendance.
· Employee maintains current licenses and/or certifications required for the position.
· Practices and reflects knowledge of HIPAA, Accreditation Organizations (such as ACHC, CHAP), OSHA and other federal/state regulatory agencies guiding healthcare.
· Completes all annual education and competency requirements, as assigned, within the calendar year
· Is knowledgeable of UPaH, Ambulatory, and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of UPaH leadership. Takes appropriate action on concerns reported by department staff related to compliance.
Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
Identify items that are minimally required to perform the essential functions of this position.
Preferred or Specialized
Not required to perform the essential functions of the position.
Graduate of State Board approved program for Registered Nurses.
Complete and maintain UPH Person-Centered Care: Three opportunities completed per year required (Oct – Sept scheduled year).
Attend all mandatory education programs.
BSN or BS in health related field.
Masters education in health related field.
PICC line and Chemotherapy certification
Strong interpersonal skills.
Ability to work as a collaborative team member.
Ability to understand and apply guidelines, policies and procedures.
Strong computer skills.
Previous home care experience or demonstrated clinical efficiency.
Valid / maintained license as a Registered Nurse for all states applicable to practice.
Valid / maintained Basic Life Support (BLS) Healthcare Provider Card with Re-certification.
Valid / maintained Mandatory Reporter course by state(s) requirement.
Valid / maintained driver’s license and automobile insurance in accordance with state and/or organizational requirements.
Writes, reads, comprehends and speaks fluent English.
Microsoft Office – basic computer skills.
Critical thinking skills using independent judgment in making decisions.
Use of usual and customary equipment used to perform essential functions of the position.
Required to drive personal vehicle to perform essential functions of the position. Mileage reimbursement provided per policy.
Work may occasionally require travel to other UPH facilities. May drive a UPH vehicle, rental or own vehicle.