The RN Care Manager manages all aspects of the patient’s home health care from the start of care through discharge in collaboration with team visit nurses and other disciplines as determined by the needs of the patient. He or she determines patient eligibility for care, completes most OASIS assessments, and develops evidenced-based individualized care plans following established professional standards of care, Agency policies, and State, Federal laws and regulations. The RN Care Manager is integral to optimal quality and process outcomes.

1. Responsible for continuous review of all aspects of assigned patients to include: appropriate utilization of services; monitoring of skilled care need and homebound status; patient safety; medications; review of documentation in the medical record; maintenance of interdisciplinary communication; and discharge planning.
2. Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness/es.
3. At the initial assessment, explains patient’s rights and expectations, HIPAA as it relates to confidentiality of medical information and OASIS data, advance directives, and informs the patient and family of expected disciplines and frequency. Reviews changes as they occur throughout the episode of care.
4. Develops a plan of care that corresponds with physician orders, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and family in the planning process. Makes revisions to the plan of care as patient status and needs change. Communicates as needed with and updates the primary physician when necessary and at least every sixty (60) days.
5. Re-assesses patients within 24-48 hours following a change in condition or discharge from an inpatient setting and updates the plan of care.
6. Uses health assessment data to determine nursing diagnosis.
7. Establishes positive working relationships with physicians and physician’s office staff and keeps them informed of patient’s problems and progress towards goals as appropriate.
8. Counsels and provides instruction to the patient and family in meeting nursing and related needs.
9. Provides quality patient care.
10. Provides supervision of LPNs and home health aides per regulatory requirements.
11. Maintains responsibility for all assigned patients and schedules patient care for maximum efficiency in collaboration with team visit nurses and other disciplines
12. Presents patients at IDT patient conferences.
13. Rotates night, weekend, and holiday call to facilitate adequate coverage for all patients.
14. Supports and promotes Agency policies and practices.
15. Maintains communication with team members.
16. Maintains a continuing knowledge of competencies related to the Nursing profession by participation in Agency sponsored education and training as well as personal growth through independent study
17. Attends mandatory Agency meetings and in-services.
18. Participates in Quality Improvement and Corporate Compliance activities as assigned.
19. Assists with other chart audit activities as assigned.
20. Meets daily average productivity standard.
21. Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
22. Performs compliance requirements as outlined in the Employee Handbook
23. Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
24. Requires use of electronic mail, time and attendance software, learning management software and intranet.
25. Must adhere to all DCH Health System policies and procedures.
26. All other duties as assigned.

Registered Nurse with a current Alabama license.  One (1) year of registered nurse clinical experience required. BSN preferred.  Prefer extensive clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease processes and care needs. Prefer Working knowledge of OASIS and working knowledge of computer systems. Excellent coordination and communication skills. Detail oriented and able to work with minimal supervision. Must be able to read, write legibly, speak, and comprehend English. Must have current BLS certification or be able to obtain within 60 days of employment and before first independent patient visit.

WORKING CONDITIONS

Is able to lift 50 pounds, turn and position patients weighing over 200 pounds.  Ability to stand, walk, kneel, sit, crouch or stoop with good balance for extended periods of time.  Must be able to maneuver over a variety of uneven surfaces including fields, grass, ditches, gravel, concrete, wood, vinyl, or carpet.  Good manual finger dexterity.  Must have good communication skills.  Must be licensed and insured to operate a motor vehicle.  Must have tolerance in a variety of environments to include the presence of pets and infestation.

Physical presence onsite is essential.  Hearing and vision must be normal or corrected to within normal range.  Able to perform the duties with or without reasonable accommodation.