Home Health RN Case Manager

Working Title: Home Health RN Case Manager Classification Title: Registered Nurses (29-1141) Division: Home Health Program: Home Health Reports to: Home Health Clinical Manager FLSA Status: Non-Exempt Schedule: Full-Time or Part-Time; Monday-Friday; 8am-5pm Wage Range: $31.48 to $44.37 hourly, including $2 Case Management stipend; due to years of transferrable experience and internal equity

RiverStone Health Serving the Yellowstone County community and south-central Montana for nearly 50 years, RiverStone Health is an essential provider of personal and public health services. Health, Education, Leadership and Protection - HELP is what we do. From medical, dental and behavioral healthcare; Home Health and Hospice; public health services like immunizations, WIC, health promotion and restaurant inspections; and educating the next generation of health professionals, our expertise spans all ages and stages of life. Underlying principles of access, affordability, compassion and quality in all interactions, RiverStone Health improves life, health and safety for all communities we serve.

Home Health Overview RiverStone Health Home Health Services provides medical treatment for an illness or injury, to help patients recover, regain independence, and become as self-sufficient as possible. Home health care helps patients manage chronic conditions like heart disease, diabetes, pain management, or chronic obstructive pulmonary disease (COPD) and provides personal care services. Home Health Services may be requested by physicians, the patient or family member, or a hospital discharge planner. Through consultation with the patients healthcare provider, Home Health Services develops a plan of care to meet the patients individual healthcare needs. The team includes nurses, physical therapists, occupational therapists, speech therapists, medical social workers, and certified home health aides.

Job Summary The home health nurse case manager is responsible for the delivery of quality patient care through the nursing process of assessment, nursing diagnosing, planning, implementation, and evaluation. In tandem with the clinical manager and clinical nursing staff, the nurse case manager helps to oversee patient care, nursing case management, clinical documentation (OASIS), referral staff, and customer satisfaction with home health patient care services. The incumbent brings content expertise and knowledge surrounding the program elements, deliverables, and metrics. The work environment is typically fast paced. Work is performed to ensure efficiency of program delivery, incorporating integrity and innovation to ensure a high level of customer service.

Essential Functions/Major Duties and Responsibilities

Case Management (95%) The ability to work independently and collaboratively to provide and direct skilled comprehensive nursing care and instruction for patients and families based on established clinical nursing practice standards. This includes but not limited to:

• Administering care, treatments, medication in compliance with physicians orders
• Monitoring and interpreting symptoms and treatments; developing a plan of care in collaboration with other health care providers
• Providing education to patients and families
• Responsible for completing admissions and home visits assigned. This includes:
• Initiating the plan of care and priority setting to ensure effective and efficient patient care delivery and achievement.
• Consult and coordinate with the health care team members to assess, plan, implement and evaluate patients plan of care.
• Following a plan of care that assures the patient and family needs are identified, prioritized, and met in order to achieve desired clinical outcomes/goals.
• Regularly reevaluates the patients nursing needs and makes the necessary revisions in the plan of care.
• Assures that care, educational and discharge planning needs of patients are met.
• Teach patients and families preventative care, disease prevention, medical and psychological care, and medication review.
• Monitors ongoing patient care, through care conferencing and review of documentation, to determine care, educational and discharge planning needs.
• Utilizes knowledge of patients age and cultural diversity in the provision of patient care and education needs.
• Evaluates discharge outcomes to look for improvements or decline and any discrepancies.
• Responsible for supervisory visits with Licensed Practical Nurses (LPN) and Certified Home Health Aides (CHHA).
• Communicates a report to the appropriate health care team members for the continuation of care, including reporting any changes in patients condition to the physician and family as needed.
• Demonstrates the knowledge and skills necessary to provide care appropriate to patients of all age groups-must demonstrate knowledge of the principles of growth and development through the life span, possess the ability to assess data reflective of the patients status, and interpret the appropriate information needed to identify each patients needs.
• Maintains universal precautions guidelines and safety measures according to RiverStone Health policies and procedures
• Documents are provided for the patients encounter in the electronic medical records (per documentation standards) in a timely manner. Must document/chart observations, activities and other data relate to the clinical condition of the patient and patient care.
• Experience in Outcome and Assessment Information Set, OASIS-E, quality and reimbursement measures which include structure, process and outcomes is preferred, but not required.
• Contributes to the provision of quality process through performance improvement techniques that demonstrate positive outcomes in patient care. Receives and works to resolve patient/family concerns/complaints.
• Maintain knowledge of and compliance with current Medicare/Medicaid, state regulations and rules, Health Insurance Portability and Accountability Act (HIPAA) compliance and accreditation regulations for home health services.
• Maintain and enhance professional growth and development through attendance in orientation, continuing educational offerings as well as organizational educational programs as requested.
• Demonstrates interpersonal, cognitive, and technical competencies and standards of care consistent with the programs and organizations mission, values and services.
• The ability to help cover needs in home care as assigned.
• Must carry a program computer and telephone to receive and place calls for patient care operations during non-office hours when on call.

Non-Essential Functions/Other duties assigned (5%)

• Perform other duties as assigned in support of RiverStones mission and goals.

Education and Experience

• Minimum Qualifications:
• Associate degree in Nursing.
• Any combination of experience and training which provide the equivalent scope of knowledge, skills, and abilities necessary to perform the work.
• Preferred Qualifications:
• Bachelor of Science in Nursing
• Two years of nursing experience preferred.
• Knowledge of nursing process and home care regulations preferred.

Certificates, Licenses, Registrations

• Current license as a Registered Nurse in Montana.
• Valid State of Montana Drivers License and vehicle insurance (if Hospice, Home Care, and Public Health)
• BLS and CPR certification required

Knowledge, Skills, and Abilities

• Computer literacy, in Microsoft Office Suite.
• Ability to maintain a calm and positive demeanor during difficult interactions.
• Ability to display non-judgmental and empathetic listening skills.
• High degree of detail-oriented skill level.
• Knowledge and understanding of protected sensitive patient health information (HIPAA) and confidentiality.
• Ability work collaboratively to maintain a positive work environment.
• Ability to prioritize and perform a wide range of tasks under pressure of continuous interruptions.
• Ability to perform job duties with integrity and innovation to ensure completion and a high level of quality.
• Ability to understand and adhere to required administrative policies and procedures.
• Excellent communication skills to ensure efficiency and quality customer services.

Customer Service Excellence

• Doing things right the first time
• Making people feel welcome
• Showing respect for each customer
• Anticipating customer needs and concerns
• Keeping customers informed
• Helping and going the extra mile
• Responding quickly
• Protecting privacy and confidentiality
• Demonstrating proper telephone etiquette
• Taking responsibility for handling complaints
• Being professional
• Taking ownership of your attitude toward Service Excellence.

Supervision None

Physical Demands and Working Conditions

• Required to stand, walk and sit; talk or hear, both in person and by telephone; use hands to finger, handle or feel objects or controls; reach with hands and arms.
• Regularly required to stoop, kneel, bend, crouch and lift up to 25 pounds frequently and 50 pounds occasionally; expected to ask for help from a colleague or utilize a lift when assistance is needed.
• Specific vision abilities required by this job include close vision, distance vision, depth perception, color vision and the ability to adjust focus.
• Ability to travel within service area and use own personal vehicle. Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, other vehicles, etc. Travel occurs in all weather conditions, including extreme heat and cold.
• Risk of needlestick injury is possible.
• Position is regularly exposed to biological pathogens and contagious diseases where Personal Protective Equipment (PPE) and special precautions must be taken due to reduce exposure and mitigate risk.
• Will be exposed to home environments that may include allergens such as smoke, pets, etc.
• Create and maintain a safe/secure working environment by adhering to safety, security, and health requirements. Integrate injury, illness, and loss prevention into job activities by attending any necessary training and implementing best practices.

Freedom to Act & Decision Making Work is structured by regulations and established nursing practices. The position makes independent professional judgements regarding patient health. Decisions directly affect the quality of services provided to the public.

Communications & Networking

• Contacts occur both inside and outside RiverStone Health and typically are for the purposes of rendering services to patients to gather information and provide education and instruction.
• Communication with others is a critical element of the position because the purpose of the contract may be to negotiate matters involving significant issues of importance.
• Communicate and coordinate with others to maximize the effectiveness and efficiency of interagency operations and activities.

Budget & Resource Management Responsible for the maintenance of equipment and management of resources pertaining to the program budget.