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Registered Nurse Case Manager - Home Health

Company: Residential Home Health and Residential Hospice
Location: Harrisburg
Posted on: August 14, 2019

Job Description:

Job TitleRegistered Nurse Case Manager - Home HealthLocationHarrisburg, PA, USAEmployee TypeEmployeeWorking Hours Per Week40Job Functional Area

Job Description

SUMMARY: The RN will coordinate the home care of chronically ill patients by utilizing a disease management process, the OASIS assessment, plan of care and established protocols. Will also educate the patient/caregiver in the management of their illness and promote the home health support systems to decrease re-hospitalization and utilization of hospital emergency services.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned as necessary.

--- Review the home health referral, updating & communicating any changes to other disciplines and to customer service center.

--- Perform assessments within 24-48 hours of receiving a referral.

--- Complete Start of care papers and forward to the office promptly.

--- Develop rapport with the client and family ensuring privacy and confidentiality while obtaining accurate client history.

--- Complete a physical assessment and communicate the findings and plan of care to the physician.

--- Initiate evaluations to other disciplines (PT,OT,HHA,SLP,MHRN,MSW) or support services when indicated.

--- Conduct Home health aide supervisory duties as required by state regulations.

--- Document accurately and appropriately on the laptop during each visit, uploading by midnight.

--- When appropriate, enter insurance authorization requests within 24 hrs of initial evaluation and continue to enter additional requests at the end of each authorization period.

--- Organize daily assignments, setting priorities based on individual and overall needs of the clients while traveling to each home as scheduled.

--- Ensure the clients have prescribed medications and/or treatment supplies, updating file as changes occur.

--- Identify appropriate actions that will provide for continuity of care, an individualized teaching plan and the involvement of the individual and family/caregiver whenever possible.

--- Formulate a plan of care to achieve expected outcomes through short and long term goals that are realistic and feasible in terms of resources, time, material, people and cultural relevancy. Revise the plan of care in response to changes in the individual's status or to adjust to the individual's response to care, and communicate and update with all disciplines, including PPL.

--- Coordinate discharge planning with direct involvement of client, family/caregiver.

--- Document any communication and/or orders from the physician.

--- Attend PCH/ALF case conferences as scheduled providing weekly client reports to team and provide PCH/ALF monthly educational inservices as requested by facility.

--- Maintain a high level of competency, growth and development, including ensuring license and CPR are current and in good standing at all times.

--- Attend nursing staff meetings, quarterly educational in-services and yearly competency day.

--- Perform on-call duties per agency requirements/assignment for non-business hours. Position may require after hours patient visits to achieve positive patient outcomes.

--- Follows agency policies and procedures as per the Policy and Procedures of the company.

--- Adhere/assist with company outcome goals as indicated by QI/home health compare tracking.

--- Follow guidelines as indicated in employee handbook

--- Participate in QA/OBQI initiatives with problem-solving via action items.

--- Perform other duties as assigned by management.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

--- Must be able to meet the physical demands of providing nursing care, ambulating patients, transferring patients, assisting with exercises, etc.

--- Must be able to transfer patients as needed according to proper techniques of body mechanics to promote patient and staff safety.

--- Must be able to use good and sound clinical judgment.

--- Must be able to document accurately and appropriately.

--- Must follow up as needed and appropriately with doctor's office, clinical and management staff pertaining to any concerns regarding patient care.

--- Must hold, in good standing, a license as a Registered Nurse, issued by the state in which you work

--- CPR certified.

--- Must be empathetic, non-judgmental, tactful, responsible, and organized.

--- Must understand the team approach and be a supportive team member.


--- Must possess an Associate Degree from an accredited School of Nursing.

--- A minimum of two (2) years of experience working as a Registered Nurse including some medical/surgical experience and/or an acute care or home care setting is preferred.

Education & Certifications

CompanyResidential Home Health of Carlisle, Inc.Graham Healthcare Group is an Equal Opportunity Employer

Keywords: Residential Home Health and Residential Hospice, Harrisburg , Registered Nurse Case Manager - Home Health, Executive , Harrisburg, Pennsylvania

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