Job Description Type of Opportunity: Full Time FTE: 1.000000 Exempt: No Work Schedule: Days
Summary:Responsible for case management of Home Healthcare patients. Ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state. Responsible for development, coordination and scheduling delivery of care through a multidisciplinary team to the patient in the home or community setting. The Case Manager assures completeness, timeliness and appropriateness of the patient care plan, its implementation and ongoing evaluation. Assures communication with the multidisciplinary team, support services and community resources to ensure that care goals are achieved in the most efficient and cost effective manner possible. Ensures that documentation is timely, accurate, complete and reimbursable. Is a patient advocate. Precepts newly hired nurses. . PRN staff will not be responsible for managing a caseload; but all staff are required to manage the case load, follow up and communication for their daily assignments.Responsibilities
Responsibilities:*Demonstrates nursing care management of patients as evidence by a. Assessments that are complete, timely, and appropriate of physical, mental, psychological/social (behavioral), functional, financial, treatment, resource and spiritual needs of patients.b. Analysis that defines problems that are capable of correction through home healthcare and hospice interventions and are prioritized in development of care plan.c. Intervenes consistently with orders and changes interventions with orders to meet changes in patient needd. Evaluates each visit the effectiveness of interventions and the patients response to intervention.*Provide direct patient care by assessing patient for care needs, resources to meet needs and developing a home care or hospice plan of care in conjunction with physician. Assures completion of required OASIS assessments according to regulations for home care and QAPI measures for hospice .*Coordinates implementation of the plan of care through a multidisciplinary home care or hospice team, community resources and the physician*Ensures plan of care is followed and that documentation complies with regulation.*Maintains a department productivity standard for visits and caseload management.*Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration, and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met.*Assure patients on case load are notified timely of their visits and of any unplanned schedule changes accommodating, when possible, patent preferences for time of day. *Precepts newly hired nurses, and students and serves as a resource person and professional role model as needed.*Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and assures that changes are communicated timely to the team. *Initiates documentation in the home and completely records all care delivery so that receiving staff have record of care delivered by the end of each day which includes admissions.*Demonstrates proficiency and competency in interventions (treatments) required through day to day practice and annual competency testing.*Delegate or assign aspects of patient care to health care team members commensurate with their validated competency to perform the task.*Be professionally responsible for current nursing research, current nursing standards, home care or hospice philosophy in order to maintain quality.*Be responsible for clinical supervision of licensed and non-licensed assistive personnel.*Participates in agency continuous quality improvement activities as required.*Assume other leadership roles as required by the department.*Responsible for weekend and holiday coverage and evening call for agency and patient home visits as required on a rotating basis.*Assure clinical outcomes are met and sustained .*Performs other functions as required.
*Minimum one year acute care experience within the last 3 years required and hospice or home care experience preferred.. Basic typing competency Need to have current drivers license as well as auto insurance. Education:Essential:* Associate Degree
Credentials:Essential:* Registered Nurse-NM
Competencies and skills:* Caring Practices: Incorporates nursing activities that create a compassionate, supportive and therapeutic environment for patients and staff with the aim of promoting comfort and healing and preventing unnecessary suffering. Critical Elements of Caring Practices Performance *Applies The Promise and incorporates into care interactions. *Applies Exceptional Patient Experience principles and incorporates into care interactions *Applies respect and timely response in interactions with patient, family, health care team members *Interacts with patient and family providing compassionate, non-judging, empathetic care * Clinical Judgment and Action: Uses clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the patient care situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines to manage patient care. Critical Elements of Clinical Judgment and Action Performance *Consistently uses the nursing process to structure and revise care *Anticipates, recognizes, and responds to changes in condition *Accurately communicates with healthcare team members to relay changes in patient status *Consistently provides care based upon need and urgency *Consistently applies patient safety principles *Develops, plans, and evaluate patient short and long term care goals. Charts problems, plans and goals appropriately in NICP *Consistently follows policies, procedures, standing order sets, care bundles, core measure practices *Consistently follows red rules: Patient identification and hand-washing *Seeks consultation if uncertain on how to respond to patient needs *Adjusts care to establish and support care goals *Integrates technology into daily care of patient by appropriate initiation of technology, maintenance, troubleshooting, and discontinuation *Consistently and accurately documents care per policies & standards * Patient Advocacy: Works on behalf of the patient/family representing their concerns and helps resolve ethical and clinical issues that impact the patient situation. Critical Elements of Patient Advocacy Performance *Maintains patient confidentiality/personal/medical information *Identifies ethical and clinical issues *Acts with integrated healthcare team using appropriate resources to resolve ethical/clinical issues *Advocates for patient needs, values, and goals *Compliance with JC Rights and responsibilities of the Individual elements * Clinical Inquiry: Uses high standards and evidence-based practices along with questioning, research and evaluation skills to provide informed and/or change practice Critical Elements of Clinical Inquiry Performance *Supports process/quality improvement initiatives and incorporation into practice *Follows and is informed on Department outcome measures *Actively participates in changes in practice/roll outs *Seeks advice and consultation on care from colleagues and interdisciplinary team * Collaboration: Involves multidisciplinary team as well as patient/family to promote optimal and realistic goals and outcomes Critical Elements of Collaboration Performance *Provides and coordinates independent, interdependent, and dependent care interventions with interdisciplinary care team *Selects appropriate Screenings from HED to facilitate interdisciplinary care when needed *Appropriately delegates care, monitoring delegated team members care and responds as appropriate with the goal of optimizing care *Interactions with care team in respectful, professional manner * Facilitation of Learning: Fosters patient/family learning to promote self-care using both formal and informal processes as applicable and at an appropriate level of understanding. Critical Elements of Facilitation of Learning Performance *Self: Completes all required learning modules, programs in specified time *Self: Uses available resources within system to enhance own continuous learning *Self: sets and achieves learning and performance goals yearly *Self: Consults, teaches, supports continuous learning with colleagues *Self: Actively seeks learning/mentorship *Patient: Assess patient's learning style, readiness to learn, challenges to learning and adapts patient education to meet needs *Patient: Incorporates patient in learning about diagnosis(es), care management, medications using appropriate verbal and written communication tools/resources* Response to Diversity: Uses holistic body, mind, spirit approach in provision of care by recognizing, appreciating, and incorporating cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and value differences in practice. Critical Elements of Response to Diversity Performance *Provides communication/ medical interpretation services for population served based upon language preference *Consistently provides care to population served with appreciation to diversity elements as designated above *Consistently communicates and documents patient diversity needs *Uses PHS established internal resources and vendors * System Thinking: Manages environmental and system resources across the healthcare system and community to meet patient/family needs or provision of quality care. Critical Elements of Systems Thinking Performance *Utilizes internal and PHS resources to provide evidence-based care including policy, protocols, procedures, approved specialty resources *Incorporates all patient safety technology, tools, protocols, communications, and initiatives to optimize a safe patient environment *Deploy in the clinical environment processes to enhance care efficiency, cost containment *Plan, maneuver, and deliver services/technology that are available within the system to meet the care needs of the patient *Negotiates within the system to achieve the care needs of the patient * SKILL-Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, and physician office staff using strong dialogue and customer service competencies. * SKILL-Written communication Benefits
Benefits Benefits are effective day-one (for .45 FTE and above) and include:
- Competitive salaries
- Full medical, dental and vision insurance
- Flexible spending accounts (FSAs)
- Free wellness programs
- Paid time off (PTO)
- Retirement plans, including matching employer contributions
- Continuing education and career development opportunities
- Life insurance and short/long term disability programs
About Us Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans. We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come. About New Mexico New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great. Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC. New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.