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 Administrator, 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 health services.
- Assess and evaluates patient needs/problems, identifies mutually agreed upon goals with patients
- Reports patient status and need for other disciplines to agency Intake Coordinator, RN Manager, and referring Physician
- Develops patient care plan that specifically addresses identified patient problems, nursing problems, and goals.
- Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or recertification
- Assures that all admit paperwork is completed in full at time of submission for timely data entry of IDG/POC information
- Provides intermittent Skilled Nursing services including assessment, evaluation, procedures, teaching, and training activities as outlined in the patient IDG 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 RN Manager as they occur
- Submits completed skilled nursing notes; communication notes and home health aide supervisory notes per policy
- Submits change orders within 48 hours of occurrence
- Submits recertification paperwork by the due date provided by the RN Manager
- Schedules an IDT meeting with assigned RN Manager to review patient's needs, problems, level of care and any changes in Plan of Care for next cert period
- Completes communication note documenting plans for recertification were discussed and agreed upon between the physician, patient, and RN Manager
- Completes other required documents for recertification: new Medication Profile, updates Care Plan, and updates or completes new HHA Plan of Care, if applicable
- Performs home health aide supervisory visits
- Effectively communicates with all members of the healthcare team
- Acts as the patient's advocate, and, as such, is a liaison to assist in communicating the patient's needs to the multidisciplinary team
- Reports identified performance related problems; patient complaints and/or deviation from the Hospice Aide instruction sheet to the RN Manager
- Acts as a preceptor in the orientation of new nursing staff
- Attends staff meetings and educational in-services per agency requirements
- Continually strives to improve nursing care by broadening knowledge through formal education, attendance at workshops, conferences and participation in professional and related organizations and individual research reading
- Obtains CEU's as dictated by the State Board of Nurses
- Attends at least 50% of the skilled nurse in-services and meetings provided by agency
- Is responsible for obtaining information provided at skilled nurse in-services and meetings and demonstrates appropriate follow-up related to information given at meetings and in-services
- articipates in PI program through submission of data collection as it relates to direct patient care problems and serving on PI teams
- Follows agency policies and procedures
- Participates in discharge planning process
- Documents Discharge Planning beginning with admit and documents at least 2 weeks in advance instructions given related to discharge
- Completes Patient Care Plan, Discharge Nurse's Notes, and submits them along with other notes turned in per agency policy
PREFERRED KNOWLEDGE, SKILLS, AND EXPERIENCE
- Active CPR Certification
- Is currently a Registered Nurse in the state of practice or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC)
- Ability to work in a field setting and exhibited ability to make sound nursing judgments
- Ability to assess patient needs and formulate individualized patient care plans to meet those needs
- Effective communication skills
- Must have and maintain an automobile to be used for work
- One year experience as a professional nurse preferred
A little about us:
Our mission is to provide high quality, compassionate and cost-effective care to our patients through clinical leadership, outcomes management and maintaining an ethical workplace.