Reports To: Clinical Supervisor
- Is currently a licensed Registered Nurse in the State of California.
- Has at least one-year experience as a professional nurse.
- Has excellent clinical judgment, knowledge of current nursing practices, observation, and communication skills.
- Current CPR Certification.
- Current and satisfactory report on pre-employment physical examination including Mantoux TB Test or chest X-ray as required by Agency policies and procedures.
- Able to walk, bend, stoop, and lift objects weighing up to 25 lbs.
- Is fluent in English.
- Is self-directed and able to work with little supervision and has good organizational skills.
- Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.
- Is able to use professional judgment in reporting and seeking assistance from both peers and supervisors.
The Case Manager will use the nursing process to assess and manage the medical needs of the patient. The Case Manager identifies other disciplines needed to maximize the patient’s progress toward goals. The Case Manager will be the patient’s advocate and will be in communication with the primary MD and the Clinical Supervisor, as the patient’s condition requires.
ESSENTIAL DUTIES AND RESPONSIBILITIES
The following is representation of the major duties and responsibilities of this position. The Agency will make reasonable accommodations to allow otherwise qualified applicants with disabilities to perform essential functions.
- Assesses all patients initially, choosing appropriate parameters for measurement and observation related to the patient’s medical history/disease process, nursing assessment, functional limitations and the Plan of Care.
- Initiates the plan of care.
- Provides the ongoing periodic assessment of the patient, monitors patients for all important parameters on each visit; utilizes monitored information to progress therapy/intervention toward goals and revises the Plan of Care as needed.
- Notifies the patient’s attending physician, dentist or podiatrist and other professional persons and responsible staff of all significant changes in the patient’s condition and needs. “Significant change” includes those changes that suggest the need to modify or develop a plan of treatment or plan of care.
- Carries out the physician’s orders as directed; clarifies orders.
- Regularly re-evaluates the patient’s nursing needs.
- Follows current standards of clinical nursing practice with appropriate adaptations for delivering care in the home environment.
- Gives clear and precise explanations to the patient and family caregiver about services the Agency provides, their rights and how to exercise them while receiving services. Informs patient/PCG of the reasons for treatment and any responsibilities they may have following the treatment. Promotes participation in developing the Plan of Care to the extent they are willing and able to participate.
- Counsels the patient and family in meeting nursing and related needs.
- Assists in coordinating all services provided.
- Educates and instructs the patient, patient’s family, or staff as required.
- Identifies problems for which nursing services are to be provided and selects those that can be addressed within the scope of services offered by the Agency and focuses on goals that are realistic, obtainable, measurable and patient-centered.Begins planning for discharge when treatment goals are being attained or when no longer attainable. Prepares the patient/PGC for discharge by clearly instructing them on the continuing treatment and health care behaviors that need to be followed after skilled services have been discontinued.
- Coordinates patient care and discharge planning with the physician, other members of the health care team and with community services, including referrals for continued services as needed.
- Provides instruction to the patient and/or caregiver regarding but not limited to medications, disease process, treatment, safety interventions, and ADL/IADL care. Incorporates patient’s knowledge deficits into the teaching plan. Promotes self care and treatment independence in a positive manner that allows the patient control over aspects of his/her life that have been changed by acute and chronic illness.
- Maintains current knowledge and skills for documenting care meeting Regulatory and third party payer requirements. Prepares documentation and clinical/progress notes. Documents clearly and concisely, using proper notation and Agency abbreviations. Submits all documentation (notes, change of orders, progress summaries, re-certifications, transfer/discharge, etc.) within the timelines established by the Agency.
- Collects and completes the Outcomes Assessment Information Sets developed and mandated by HCFA. Submits data sets within the guidelines established by HCFA.
- Reports all events/occurrences that pose an actual or potential risk to patients or Agency personnel and completes an Incident/Accident Report as required by Agency policy when necessary.
- Reports/submits all other quality indicator data as required by Agency policy (i.e. glucometer logs, patient grievances, patient/employee infections, etc.).
- Manages all hazardous materials and wastes in a prudent and cautious manner according to Agency policy.
- Establishes a supportive relationship with patient and caregiver that promotes a climate for caring and for mobilizing the patient’s own resources.
- Utilizes additional community services appropriately. Incorporates advocacy into the Care Plan by providing information or direct advocacy to obtain medical care, other health care services, equipment and supplies when necessary.
- Respects the patient’s and family’s rights and property as defined by the federal and state laws. Keeps all patient information confidential.
- Regularly attends and participates in scheduled case conferences, staff meetings and Agency in-services.
- Supervises Home Health Aides every 14 days in the home and or as required. Supervises LVNs as required. Teaches other nursing personnel.
- Regularly assesses own nursing skills and educational needs to meet the nursing care requirements of patients assigned for care. Upgrades professional skills and attends in-services and continuing education classes as needed.
- Provides those services requiring substantial and specialized nursing skills in accordance with the plan of treatment or plan of care.
- Will perform duties consistent with the Nursing Practice Acct including the Standards of Competent Performance, Title 1, Chapterl4, 1443.5 of the California Code of Regulation.
- Conforms to all Agency policies and procedures.