Field RN Case Manager - Care at Home

Variable (United States of America)

Field RN Case Manager - Care at Home

The Registered Nurse plans, organizes, and directs home care services and is experienced in nursing with emphasis on community health education/experience. The professional nurse builds from the sources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

• Current Florida Nursing License required 
• Must have at least one (1) years experience in home health care or the acute care setting
• Nursing staff education experience preferred.
• Demonstrated effective organization and time management skills.
• Demonstrated ability/possession of interpersonal skills.
• Demonstrated excellent knowledge of current nursing and patient care practices and the ability to learn and teach new concepts.
• Demonstrated ability to apply nursing theories and trends appropriately in the clinical setting.

• Admits patient to service per established procedure:

• Completes an initial assessment of patient and family to determine home care needs. 
• Evaluates home environment to assure services can be safely provided in the home
• Obtains a complete physical assessment and history of current and previous illness.
• Advises patient of rights on initial visit.
• Includes the patient and the family in the planning process.
• Uses health assessment data to determine nursing diagnosis
• Develops a plan of care, which establishes goals based on nursing diagnosis  and incorporates therapeutic, preventive, and rehabilitative nursing actions. 
• Initiates the plan of care and makes necessary revisions as patient status and  needs change.
• Furnishes services requiring substantial and specialized nursing skill through  the initiation of appropriate preventive and rehabilitative nursing procedures.
• Administers medications and treatments as prescribed by the physician.
• Completes start-of-care and comprehensive assessments, and updates, within  established time frames.
• Maintains the electronic clinical record for each patient receiving nursing care.
• Regularly re-evaluates patient's nursing needs. 
• Revises plan of care based on changes in physician orders.
• Provides health care instructions to the patient as appropriate per assessment  and plan of care.
• Counsels the patient and family in meeting nursing and related needs.
• Completes start-of-care and comprehensive assessments, and updates,  (including a drug regimen review) within established time frames.
• Identifies discharge planning needs as part of the care plan development and  implements prior to discharge of the patient.
• Acts as Case Manager in all cases involving nursing or both nursing and  therapy care when assigned by Clinical Supervisor and assumes responsibility  to coordinate patient care for assigned caseload.
• Documents case conferences to demonstrate that effective interchange,  reporting and coordination of patient care took place.
• Instructs, supervises and evaluates home health aide care provided every two  (2) weeks.
• Maintains accepted standards of productivity.