Home Health RN Case Manager

Job Overview 

Utilizing the nursing process, the Home Health Registered Nurse will manage and deliver comprehensive home health services, including assessments, interventions, and supportive care to clients within their place of residence.  Depending on the circumstances, duties may also include telephone triage, problem solving, patient/caregiver advocacy and support, with emphasis of avoiding hospitalization. As a key member of the health care team, this position must interact courteously and effectively with patients and their families as well as with co-workers from all Agency departments, community resources, and with patients' physicians in order to facilitate safe and efficient patient care while maintaining their own safety in the home and the community at large.

Job Description 

Minimum Qualifications: 

1. Massachusetts RN Licensure and NH Licensure.

2. Valid state issued Driver’s License. 

3. One (1) year of acute medical/surgical nursing experience. 

4. Basic Life Support Certification. 

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned. 

• Assesses patients' physical, psychosocial needs in a sensitive, caring manner following established Standards of Nursing Practice and Agency policies and procedures. Provides ongoing interdisciplinary assessment of the patient. 

• Assesses patient/family learning needs, style and limitations and makes adjustments for delivery of information. 

• Recognizes/identifies patients/caregivers’ cultural beliefs re: death and dying and is sensitive to those beliefs.  

• Establishes realistic goals and develops plan of treatment in cooperation with the patient, family and members of the health care team.

• Identifies abuse and/or neglect and identifies reporting mechanism per policy. 

• Adapts to new and unusual situations without affecting work performance negatively. Utilizes Security when and if needed for any potential unsafe situations.

• Collaborates with patient /family and other health care providers and/or community resources with planning of care and discharge. 

• Continuously assesses/evaluates patient and family progress and goal achievement, keeping Clinical Manager advised and justifying continuation and/or termination of services. 
• Documents patient data, activities, and communications in patient record using computer system in a timely, organized, concise manner to ensure compliance with legal, certification, third party payor guidelines and Agency policies.  

• Completes physicians' orders, levels of care, and OASIS on all patients assigned, in accordance with patient care policies. Reconciles medications with patient and physician consistently. 

• Demonstrates and practices according to safety guidelines and procedures including general ergonomics, fire, and personal safety.  Utilizes proper body mechanics and patient material handling. 

• Demonstrates an awareness of safety and security issues by responding appropriately to emergency situations and following established procedures and protocols utilizing stabilizing techniques. 

• Demonstrates ability to cope with patient/family emotional stress and provide appropriate supportive care. 

• Effectively manages assigned caseload, withi