Title:Registered Nurse Case Manager
Department: Home Care & Hospice
FLSA Status: Non-Exempt
Reports To: Director of Patient Care Services/Clinical Manager
Summary: RN Case Manager (RNCM) conducts comprehensive assessment, plans, organizes and directs and coordinates Home Care services, to meet the needs of patients and families within their homes and communities. In addition, the RNCM educates families and caregivers of the patient on recognizing potential symptoms and providing safe and competent care for the patient. Offers emotional and practical support for both the patient and their family or caregivers. The RNCM's primary goal is to ensure that every patient in their care receives exceptional care and services.
Essential Functions:
• Maintains good knowledge of and adheres to the agency's policies and procedures, Nursing Practice Act, state and federal Regulations related to home health/hospice services, clinical procedures/protocols and acts upon all the requirements.
• Assumes responsibility for the overall care of assigned patients as a Case Manager, who coordinates patient care services between all disciplines of the healthcare team, including PT/OT, ST and MSW, as well as provides supervision to Certified Home Health Aids (CHHA).
• RN/Case Manager completes initial Comprehensive Assessment of patient and family to determine home care needs. Provides a complete Physical Assessment, including the history of current and previous illnesses, vaccinations, surgeries, etc.
• Requests SOC order from patient's PCP, using SBAR protocol (describing situation/background of the patient, assessment findings and recommendations(order)).
• Documents assessment findings in OASIS, and submits it in the EMR system within 48 hours from the SOC date. Makes sure that all fields of OASIS are completed thoroughly and accurately according to assessed/factual data. After OASIS is validated by QA RN, RNCM completes all requested corrections and re-submits OASIS no later than 24 hours from receiving OASIS back from QA.
• Reconciles all patients' medications and documents them in the patient's Medication Profile during the Initial Assessment Visit. This includes all allopathic and complementary and alternative medicine (CAM), such as, supplements, ointments, gases (Oxygen), and herbals. Conducts drug interaction reaction check, determines severe/moderate drug interaction reaction and duplicated medications. Reports to PCP all significant drug interaction reactions, any unknown CAM products and duplicate findings within 24 hours of SOC visit by phone call, followed by submitting a Physician Order to the office to fax to PCP.
• Develops an initial plan of care under doctor's order.
• Develops an initial Plan of Care and discuss it with the DPCS and/or the Hospice Clinical Team Supervisor (HCTS) and PCP after the SOC visit.
• During the Episode of Care, RN Case Manager evaluates, and revises the patient's individualized plan of care in collaboration with the Director of Patient Care Services and/or the Hospice Clinical Team Supervisor, the Medical Director, other members of the Inter-Disciplinary Group, and the patient's primary care physician.
• Refers patients for other disciplines' evaluation (PT/OT, MSW, ST) and CHHA services as needed, reflecting these referrals in SOC order.
• Develops CHHA Plan of Care and supervises Certified Home Health Aide and licensed vocation nurses (LVN's) not less than every 14 days, as required by Medicare home health and hospice COP's and California Title 22. Provides onsite supervision of LVNs and CHHAs.
• Plans frequencies of visits, with consideration of the complexity of the patient's condition and the patient's treatments/education/services needed. Frequencies of visits are reported to DPCS and/or HCTS for approval. When approved, the frequencies are documented on SOC order and the calendar of visits is completed at the office.
• Assesses patient's needs for DMEs, and requests necessary DMEs in SOC order.
• Reports Start of Care Assessment findings to DPCS and/or HCTS in verbal or written format within 24 hours of completing the Comprehensive Assessment of the patient, including proposed MD orders.
• RN Case Manager assumes responsibility for the assigned patient caseload, including assessing, planning, implementing and evaluating all phases of the clinical care process towards desired outcomes.
• Reports patient's change in condition and requests MD order immediately, followed by documenting/faxing MD order and reporting the change in patient's condition to DPCS and/or HCTS.
• Reports to DPCS and/or HCTS and MD ALL falls of patients (with or without injuries, with or without witnesses), ALL infections and ALL ER visits/hospitalizations no later than 24 hours of occurrence/finding. Submits applicable written reports to DPCS and/or HCTS within the 24-hour time frame
• Conforms and acts upon all required by the Agency Paperwork/Reports time frames for submission of important Clinical Documentation, that are outlined in the Regulatory Document and signed by clinical staff.
• Initiates communication with PCP, DPCS and/or HCTS, Home Care team members, and other agencies as needed, to coordinate optimal patient care and the use of community resources for the patient and/or family.
• Participates in bi-weekly Mandatory Case Conference meetings, where the Professional Clinical Team discusses Patient Care, including Complicated Cases, Potential Discharges, Recertifications and other aspects of patient care. Prepares for the meeting a report on the patients who need to be discussed.
• Participates in Mandatory In-Services and Department Meetings that are conducted monthly at the Agency.
• Obtains data on physical, psychological, social, spiritual and cultural belief factors that may influence patient health status and incorporates those data into the plan of care. Monitors and revises the plan of care, as appropriate, to change patient and family needs.
• Maintains up-to-date patient records so that problems, plans, actions and goals are accurately and clearly stated and changes are reflected as they occur.
• Anticipates, prevents, and treats undesirable symptoms or secondary symptoms.
• Maintains the dignity, confidentiality, and privacy of the patient and family at any time. Adheres to the Health Insurance Portability and Accountability Act (HIPAA) laws and regulations.
• Provides holistic, patient and family-centered care to improve the patient's quality of life.
• Identifies and addresses signs of actively dying patients.
• Coordinates physical care of the patient by teaching and/or training patients, primary caregivers, volunteers, and employed caregivers, and by providing direct care as appropriate.
• Coordinates patient care plans for declining patients with after-hours on-call staff.
• Coordinates care for patients with a staff of SNF and RCFE/Board and Care facilities.
• Completes patient-related documentation; such as routine visit notes, Coordination/Communication notes, etc. within 24 hours of the shift worked.
• Coordinates and manages patient care with awareness of insurance benefits, necessary authorizations and cost containment.
• Informs the supervisor of unusual or potentially problematic patient and family issues.
• Participates in the agency's orientation and in-service training programs for professional staff, as well as quality assurance and performance improvement activities.
• Adheres to and practices diversity, equity, inclusion and cultural competency principles.
• Speaks up on issues and contributes to problem-solving.
• Provides excellent and quality care and services and promotes the agency's brand image.
• Performs other duties as assigned.
Qualifications:
• Current California RN license required.
• Bachelor's degree in nursing or healthcare-related field preferred.
• Minimum one-year professional nursing experience in home health, hospice, acute or sub-acute care required.
• Ability to work both independently and collaboratively as part of an interdisciplinary team.
• Excellent verbal and written communication skills, and strong interpersonal skills.
• Excellent time management skills.
• Compassionate and empathetic nature.
• Current CPR/BLS certification.
• Must pass health screening for TB clearance, physical examination, and background check.
• Knowledgeable of OASIS.
• Bilingual in English and Chinese is a plus.
• Must be able to travel via public transportation or personal/department vehicle for the performance of job duties. If driving, must have and maintain a valid CA driver license, satisfactory driving record, and auto insurance coverage as specified in Self-Help's policy.
Self-Help for the Elderly is an Equal Employment Opportunity/Affirmation Action Employer and we welcome diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, age, national origin, sexual orientation, disability, protected veteran status or any other characteristics protected by law. We participate in E-Verify.
Qualified applicants with criminal history will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.
We may provide reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please call (415) 677-7600 for special assistance.
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