Home Health Nurse (RN) Clinical Case Manager

JOB DESCRIPTION

Home Health Nurse (RN) Clinical Case Manager

JOB SUMMARY:

We are seeking a compassionate and dedicated Registered Nurse (RN) to join our home health care team. As a Home Health Nurse (RN) Clinical Case Manager, you will play a pivotal role in closely managing patients' chronic illnesses, with a primary focus on reducing the risk of hospitalization by identifying and addressing real-life challenges that act as barriers to better health outcomes. Employing a holistic approach, you will conduct comprehensive assessments to gain insights into the social determinants of health impacting patients' well-being. You will collaborate with patients, families, and interdisciplinary healthcare teams to develop and implement personalized care plans that promote well-being, with decreased risk for hospitalization and ED visits.

QUALIFICATIONS:

• Valid license to practice as a Registered Nurse (RN) in the state of Maryland

• Two (2) years’ nursing experience, preferred.

• Acceptance of philosophy and goals of this Agency.

• Commitment to providing compassionate, patient-centered care and upholding ethical standards of nursing practice.

• Strong assessment, critical thinking, and problem-solving skills, with the ability to adapt to changing patient needs and clinical situations.

• Excellent communication and interpersonal skills, with the ability to establish rapport with patients, families, and interdisciplinary team members.

• Reliable transportation and a valid driver's license, with the ability to travel to patients' homes within the assigned geographic area.

• Ability to work independently with minimal supervision, as well as collaboratively within a multidisciplinary team environment.

• BLS/CPR certification and other relevant certifications/licenses may be required.

RESPONSIBILITIES:

• Conduct comprehensive assessments of patients' health status, including physical, emotional, and psychosocial needs, in their home environments, using the current Outcome Assessment Information Set (OASIS)

• Assess and identify potential risk factors for hospitalization and emergency department visits through comprehensive evaluations and ongoing monitoring of patients' health status and functional abilities in their home environments.

• Identify real-life challenges and social determinants of health such as financial strain, lack of access to transportation, social isolation, and limited health literacy that hinder effective chronic illness management.

• Develop individualized care plans in collaboration with patients, families, and healthcare teams, tailored to meet the unique needs and goals of each patient, focusing on decreasing risks of hospitalization and ED visits.

• Processes orders and notifies physician of patient needs and changes in condition. Completes certification/recertification orders and discharge summaries.

• Provide skilled nursing care, including wound care, medication management, infusion therapy, and other specialized treatments, in accordance with physician orders and established care plans.

• Monitor patients' vital signs, symptoms, and overall condition, and adjust care plans as necessary to ensure optimal health outcomes.

• Educate patients and families about their medical conditions, medications, treatment plans, and self-care strategies to promote independence and improve overall health literacy.

• Document all patient care activities accurately and timely in electronic health records (EHR) systems, in compliance with regulatory standards and organizational policies.

• Coordinate with other healthcare providers, including physicians, therapists, social workers, and home health aides, to ensure comprehensive and coordinated care delivery.

• Assess and address safety hazards and environmental factors in patients' homes to ensure a safe and supportive care environment.

• Provide emotional support and counseling to patients and families, helping them cope with the challenges of illness, disability, and aging.

• Participate in interdisciplinary team meetings, case conferences, and continuing education activities to enhance clinical knowledge and skills, and contribute to quality improvement initiatives.

• Understands and adheres to established Agency policies and procedures.

• Supervises and teaches other nursing personnel.

• Participates in peer review and Quality Assessment and Performance Improvement as assigned.

• Takes on-call duty nights, weekends and holidays, as assigned.

WORKING ENVIRONMENT:

Works indoors in Agency office, remotely and patient homes and travels to/from patient homes.

JOB RELATIONSHIPS:

Supervised by: Director of Clinical Services/Clinical Manager

Workers Supervised: Licensed Practical Nurse, Home Health Aide

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.

Ability to work for an extended period of time while standing and being involved in physical activity.

Heavy lifting.

Ability to do extensive bending, lifting and standing on a regular basis.

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Registered Nurse, I will perform these duties to the best of my knowledge and ability.