Case Manager (RN) Home Health

Major job responsibilities

• 1.
• Plan, provide, supervise and document professional nursing care utilizing the nursing process for patients in accordance with the NC nurse practice act, physician orders and established policies and procedures.
• Uses professional nursing judgment to individualize the plan of care based on assessment of the patient’s baseline needs and response to care.
• 2.
• Utilize comprehensive assessment skills to plan priorities and to set realistic outcomes; collaborate with healthcare team in the evaluation and cost effectiveness of patient care.
• 3.
• Assess educational needs of patients/families concerning alterations in health, the disease process, and plan of care.
• 4.
• Develop and implement an effective discharge plan for patients to begin at the initiation of services.
• 5.
• Obtain or develop appropriate educational resources for patients/families; plan and implement appropriate educational interventions; evaluate effectiveness and outcomes of patient/family teaching.
• 6.
• Role model professional nursing through conduct, appearance, communication, mutual respect, ethical decision-making, critical thinking, and problem-solving skills.
• 7.
• Participate in weekly interdisciplinary team meetings and case conferences, as necessary, to assure appropriate care and service are provided to the patient.
• 8.
• Maintain up to date knowledge of Medicare/Medicaid/JCAHO standards thru inservices and workshop attendance.
• 9.
• Assesse the severity of patient symptoms, communicate to the physician and record significant findings, intervenes as appropriate.
• 10.
• Document care and services provided in accordance with DHCH Policy and Procedures and regulatory standards.
• 11.
• Complete documentation accurately, timely, concisely.
• 12.
• Medication reconciliation and education to prevent adverse events and readmission to hospital 13.
• Observe patient’s reactions to medications and reports significant incidents to the physicians.
• 14.
• Communicate regularly with team members, caregivers, and physicians.
• 15.
• Follow infection control standard precautions and uses personal protective equipment as required.
• 16.
• Delegate and supervise care given by NCA’s/LPN’s.
• 17.
• Develop plan of care for aides, assign care to aides based on the skills of the aide, the availability of the aide for patient care continuity, patient preference (when possible), and other considerations as determined by the patient’s care needs.
• 18.
• Identify personal learning needs and implements corrective action: assists in planning and conducting staff development programs to improve DHCC effectiveness.
• 19.
• Participate in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings.
• 20.
• Implement agency policy, procedures and objectives.
• 21.
• Work closely and collaboratively with agency billing staff to ensure accuracy of billing.
• 22.
• Maintain confidentiality of employee and patient information.
• 23.
• Exhibit an attitude which promotes harmony and goodwill in the workplace.
• 24.
• Display a clean, neat, professional appearance.
• 25.
• Participate in Performance Improvement Program.
• 26.
• Promote quality, comprehensive services through a team approach.
• 27.
• Perform other duties as assigned.

• Home Health
• Case manage interdisciplinary team of clinicians caring for patients in the home.
• Complete required OASIS Comprehensive assessments at admission, recertification, Resumption of care and discharge. This assessment determines patient reimbursement for Medicare and other episodic payors and also results in publicly reported patient outcomes and additional payment impacts related to value based purchasing
• Work with interdisciplinary team and patient providers to prevent re-hospitalization of the patient.
• Be aware of patient insurance requirements and assures authorization for all services have been obtained.
• Appropriate utilization of resources for patient including visit and supply utilization.

Work environment and requirements: Perform Patient care primarily in the patient’s residence or skilled nursing facility (>50%)

Travel to and from patient residence

Preferred Qualifications

• Education and Formal Training
• Associate Degree or Diploma, Nursing required
• Registered Nurses are not required but encouraged to enroll in a DUHS approved BSN program after completing two years of service of their start date.

• Licensures, Certifications
• Must have a current RN license in NC or compact RN licensure from participating state.
• Current State of North Carolina Cardio-Pulmonary Resuscitation Certificate (CPR) (American Heart Association only) May renew during orientation
• Valid driver's license and current automobile insurance coverage.

• Professional Work Experience
• 1-2 years of med-surgical, critical care or home health/hospice/infusion preferred
• Valid driver’s license and current automobile insurance coverage
• Prior experience in Home Health, Hospice or Infusion preferred
• Prior OASIS and PDGM experience preferred for home health

• Knowledge, Skills & Abilities
• Working knowledge of Medicare and Medicaid regulations, including JCAHO and DFS standards, ICD-9 Coding.
• Knowledge of scope of the registered nurse, licensed practical nurse and NCA
• Knowledge of and appropriate application of the nursing process
• Ability to assess nursing needs of acute and chronically ill patients and their families
• Ability to independently seek out resources and work collaboratively
• Ability to establish and maintain effective working relationships
• Ability to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership and others
• Ability to teach patients and families in accordance with the nursing plan of care
• Ability to use sensory and cognitive functions to process and prioritize information, treatment, and follow-up
• Ability to use fine motor skills
• Ability to record activities, document assessments, plan of care, interventions, evaluation and re-evaluation of patient status
• Ability to use computer and learn new software programs and technology
• Able to document and communicate pertinent information using computer and/or paper documentation tools
• Knowledge in wound identification and treatments, infusion and other advanced nursing skills
• Critical thinking skills and organization skills
• Working knowledge of infection control procedures and safety precautions
• Strong computer skills including MS Outlook, Word, Excel, preferred
• Excellent rapport, understanding, and communication with the patients and their family members
• Ability to work autonomously and independently in varying environments.
• Able to withstand driving long distances, stooping, bending, lifting 20 plus pounds, and climb stairs

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.