Job Description Summary
The Registered Nurse serves as a member of the interdisciplinary care team. The RN Case Manager participates in the development and coordinates the implementation of the interdisciplinary plan of care. The RN Case Manager plans, organizes, and provides nursing care to the terminally ill and their families.
Essential Job Functions/Responsibilities
- Provides skilled nursing patient care or service within the established plan of care.
- Coordinates all services relative to providing skilled nursing care.
- Demonstrates exceptional service to patients, families, referral sources, co-workers and other customers. Assists team members as needed to ensure that this level of service is consistently provided.
- Assesses patient physical, psychological, social, and environmental status; identifies problems and appropriate interventions and initiates the Plan of Care based on these findings. Includes the patient and family in the planning process.
- Reports pertinent observations and reactions regarding changes in patient status; identifies problems and appropriate interventions and updates the Plan of Care based on these findings. Communicates with the Clinical Team Lead and physician regarding observations and recommended interventions.
- Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
- Ensures that arrangements for equipment and other necessary items and services
are provided timely.
- Assists the patient and family/caregiver and other team members in providing continuity of care, emotional, spiritual and psychosocial support.
- Completes all documentation in a concise, accurate and timely manner.
- Provides written instructions to home health aides for patient care consistent with the established plan of care.
- Supervises home health aides on a routine basis to ensure adherence to the plan of care. Updates the home health aide plan of care as indicated.
- Provides LPN/LVN supervision as directed by the Clinical Team Lead.
- Attends interdisciplinary group meetings.
- Participates in on-call rotation as assigned by the Clinical Team Lead.
- Maintains patient confidentiality at all times.
- Takes part in timely and appropriate discharge planning when indicated by the patient's plan of care.
- Actively participates in quality assessment performance improvement teams and activities as assigned.
Registered nurse with current licensure to practice professional nursing in the state. Graduate of National League for Nursing accredited school of nursing. Prior home health or hospice experience or (1) year of recent medical/surgical experience strongly preferred. Maintains a current CPR certification. Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order. Demonstrates excellent observation, problem solving, verbal and written communications; nursing skills per competency checklist. Shows ability to organize and prioritize workload independently. Works indoors in patients' homes. May be required to work in undesirable areas. Possibility of strains due to moving patients.
Continuing Education Requirements: Organization personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. This position requires a minimum of 8 education hours. In addition, organization personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All personnel must attend mandatory educational programs.
Environmental and Working Conditions
- Environmental Conditions: May be exposed to extremes of heat and cold in all weather conditions. May be required to drive in various weather conditions on roads in varying degrees of repair.
- Working Conditions:May be exposed to infections and contagious diseases. Contact with patients under a wide variety of circumstances. May be exposed or occasionally exposed to patient elements. Subject to varying and unpredictable situations. Handles emergency or crisis situations. Travel required.
- OSHA exposure category: Category I - Position includes tasks that involve exposure to blood, body fluids, tissues.
- Required Personnel Protective Equipment: As required by working conditions.
This job description is not intended to be all-inclusive and does not constitute a written or implied contract of employment. The employee will be expected to perform other reasonably related duties as assigned by their immediate supervisor and/or other management personnel.