RN Case Manager
Pinnacle Senior Care , a CHAP accredited leader in skilled home health is leading the way into the future with its dynamic chronic care home health model. Pinnacle Senior Care is a partner of US Medical Management and owned by a Fortune 250 company. Pinnacle presents the unique opportunity to be part of a medically-centered home care provider within a continuum of care that includes Home Care, Hospice, Visiting Physicians Association, and Laboratory/Diagnostic services.
We are seeking applicants that desire the experience of changing healthcare through compassionate delivery of care. We provide opportunity for growth and advancement, with over 20 branch locations in 8 states. Positions offer:
- Partnership with Visiting Physicians Association allows staff easy access to doctors to optimize quality patient care.
- #1 operating point of care system/ Home Care Home Base.
- Ready access to professional resources such as wound care and rehabilitation specialists.
- Weekly team conferences to optimize patient care through open discussion with the interdisciplinary team.
- Flexible scheduling with very limited on-call and weekend hours.
- A Competitive salary package which includes a 401k match.
- Mileage reimbursement.
- Scrubs provided.
- Fast advancement opportunities in a rapidly expanding innovative healthcare environment offering a clinical ladder.
- A unique opportunity to provide care with specialty programs that focus on disease pathology, Health Literacy, and treating the whole patient.
- Agency is a Member of the National Association for Home Care.
Under the general supervision of the Clinical Supervisor/Clinical Manager, the RN Case Manager provides intermittent skilled nursing services, communicates the patient's progress with other disciplines, and directs, supervises, and instructs home health aide staff in the provision of personal care to the patient. ESSENTIAL DUTIES AND RESPONSIBILITIES
REQUIRED KNOWLEDGE, SKILLS, AND EXPERIENCE
- Under the physician's order, admits patients eligible for home care services within 24-48 hours.
- Assess and evaluates patient needs/problems, identifies mutually agreed upon goals with patients.
- Reports patient status and need for other disciplines to agency Clinical Supervisor and referring Physician.
- Reports to assigned follow-up Clinician as indicated.
- Develops patient care plan that specifically addresses identified patient problems; patient problems and goals. Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or at recertification.
- Completed admission paperwork and patient care plan submitted to Clinical Supervisor per agency policy following the admission including completed and signed admission checklist.
- Provides intermittent Skilled Nursing services including assessment, evaluation, procedures, teaching, and training activities as outlined in the patient Plan of Care.
- Provides Skilled Nursing visits according to visit schedule and notifies agency of need to alter schedule in any way.
- Reports significant findings to patient's physician and Clinical Supervisor as they occur.
- Submits completed skilled nursing visit notes; communication notes, and home health aide supervisory notes per agency policy on designated days as requested by Clinical Supervisor.
- Submits change orders per agency policy.
- Participates in Process Improvement (PI) program by assisting with collection of data and serves on PI team upon request.
- Performs all OASIS time point assessment per Medicare Criteria and submits recertification paperwork per agency policy and procedure.
- Maintains open lines of communications to all members of the continuum of care team.
- Supervises Home Health Aide and licenses and documents per Medicare criteria and per agency policy and procedure.
- Acts as a preceptor in the orientation of new nursing staff as requested.
- Attends staff meetings, team conferences, and educational in-services per agency requirements.
- Participates in discharge planning process Medicare Criteria and agency policy and procedure.
- Follows agency policies and procedures.
- Performs these and all other duties as assigned by the Administrator.
- A current unencumbered State professional Nurse License.
- One year experience as a home care professional nurse and is competent in performing home care comprehensive assessment.
- An automobile to be used for work, current driver's license, good driving record and proof of insurance.
- Proficiency in personal computer use, including e-mail, clinical, word processing, spreadsheet and presentation software.
- The ability to assess and document patient needs and formulate individualized patient care plans to meet those needs.
- Proficient clinical skills.
- Excellent verbal and written communication skills.