For over 40 years Pathways has been a Bay Area pioneer, leader, and innovator in Hospice, Home Health, Palliative Care, and Care Management services. We provide care at home or in settings such as assisted living, a nursing home, or the hospital. We have offices in Sunnyvale, South San Francisco, and Oakland. Patients and their families know us for our personalized, high-quality care, delivered with empathy, kindness, and respect.
TITLE: RN Case Manager - Home Health
OFFICE LOCATION: Sunnyvale, CA
PATIENT TERRITORY: Mountain View - Redwood City
SCHEDULE: Full Time (hours are flexible)
SHIFT: M-F, 1 Weekend Rotation Per Month
POSITION SUMMARY: In coordination and collaboration with the assigned Clinical Team Manager, is responsible for providing skilled nursing care to patients and their families. Coordinates care with other members of the home care team; supervises Home Health Aides. The majority of patient visit time is devoted to patient evaluations, admissions, and informational visits.
AREAS OF RESPONSIBILITY:
- Makes initial admission visits. Notifies assigned Clinical Team Manager of OASIS scores within established timelines. Notifies appropriate team members of admission and follow up plans. Performs an initial, comprehensive assessment which includes but is not limited to the patient’s eligibility for home care services in accordance with third party payer regulations, an accurate reflection of the patient’s current health status, review of all medications the patient is currently using, an environmental assessment which includes physical, social and mental status, identified needs and potential to reach treatment and discharge goals.
- Documents observations, clinical findings, problems, skilled interventions, goals and discharge plans
- In consultation with the assigned Clinical Team Manager, initiates and regularly re-evaluates and revises the plan of care.
- Assesses the need for the services of other team members (PT, OT, ST, MSW, and HHA).
- Provides and documents skilled care on all visits (includes skilled observation of the patient's condition, skilled care, and procedures and teaching of the patient and/or family).
- Obtains and documents physician orders.
- Performs Home Health Aide supervisory visits per regulatory requirements.
- Coordinates care with the assigned Clinical Team Manager, physician and other members of the home care team, informing them of significant changes in the patient’s condition and needs. Documents these communications.
- Follows established standards for point of service technology, documentation, and synchronization.
- Uses agency provided telecommunication devices (i.e. cell phone, voicemail, and pager) according to established guidelines.
- Submits weekly visit schedule of assigned patients. Collaborates with Clinical Team Manager to address scheduling needs.
- Performs re-certifications, resumption of care, transfers, and discharges as requested by the assigned Clinical Team Manager. Completes and submits all related documentation.
- Submits all documentation according to agency requirements.
- Meets established productivity standards.
- Attends and actively participates in the clinical team multidisciplinary patient conference. When attendance is not possible, provides appropriate input on assigned patients.
- Demonstrates established clinical competencies.
- Seeks out and maintains skills and knowledge relevant to skilled home care nursing.
- Participates in agency sponsored in-service education.
- Participates in quality improvement activities.
- Assists in development of agency protocols, procedures and policies as requested.
- Assesses, develops, organizes and delivers teaching materials for assigned home care patients as appropriate.
- Performs other duties as assigned consistent with skills and training and the mission and goals of Pathways.
- Graduate of an NLN accredited nursing school.
- Current California RN license.
- Minimum one year hospice or home health experience.
- Meets competencies per Pathways guidelines.
- Demonstrates experience admitting patients in all settings to Pathways services.
- Excellent clinical skills and demonstrated ability to manager time well.
- Documentation skills must meet agency standards.
- Good organization skills
- Good teaching skills.
- Maintains IV competency.
- Positive attitude and ability to confront problems constructively.
- Must be highly motivated, self-directed, flexible, and able to work well and participate in a multidisciplinary team setting.
- Demonstrates willingness and ability to work with electronic input and telecommunication devices.
- Current California driver's license and automobile insurance.
- Current CPR Certificate.
- Clinical Works
- Flexible Working