Manages the plan of care and services of assigned patients
Coordinates all disciplines involved in the assigned patients plan of care
Partners with others to effect change and produce positive patient outcomes
Provides direct care and health counseling and teaching to agency patients
Participates in the Agency's Community Wellness Program
Performs on-call and extended hours activities to meet the needs of the agency as assigned
Performs all duties in compliance with applicable federal and state regulations and Agency policies and procedures
Provides exemplary customer service to all customer contacts
Performs all other duties that management may determine necessary
Reports to the Clinical Manager
QUALIFICATIONS:
Minimum Education and Experience
The Nurse Case Manager will have one of the following: (1) B.S. in Nursing; (2) Associates Degree in nursing; (3) RN diploma from an approved school of nursing.
The Nurse Case Manager must be a registered nurse with an active license to practice nursing in the State of Connecticut who has at least one (1) years' nursing experience in an acute/sub-acute or home care setting.
Other Qualifications:
Proof of completion of an Infusion Therapy Education Program preferred
Current certification in Cardiopulmonary Resuscitation from American Heart Association or American Red Cross
Must possess a valid driver's license and personal vehicle.
Physical, mental and sensory abilities sufficient to meet performance criteria with or without assistive devices.
PERFORMANCE CRITERIA:
The Nurse Case Manager will possess the following skills and attributes to be responsible for providing direct care, health counseling and teaching to agency patients.
Utilizes sound clinical judgment and age appropriate techniques in the assessment of patients' physical and psychosocial needs for home care.
Develops and collaborates in the implementation of the home health care plan under the direction of a physician or dentist and documents the plan of care and any revisions for each patient. Documents assessments and care provided, thoroughly and accurately. Completes and submits required documentation in accordance with agency policy.
Delegates care activities appropriately to licensed practical nurses and home health aides. Orients and supervises licensed practical nurses and home health aides in the plan of care in accordance with agency policy and federal and state regulations.
Implements the physician ordered plan of care using available resources. Obtains physician or dentist orders for all changes in treatment and medical supplies. Obtains insurance authorization as needed for reimbursement.
The Nurse Case Manager partners with others to effect change and produce positive patient outcomes
Orients and supervises professional and paraprofessional personnel providing patient services.
Communicates information regarding each patient's health status and plan of care among all relevant care providers, including the home health aide and the physician or dentist. Information may include but not be limited to: Patient condition, response to interventions and teaching, changes in plan of care and discharge planning.
Reports abnormal findings or additional needs to the physician or dentist in charge of patient's care.
Makes referrals to other disciplines when indicated and ordered.
Provides supportive and restorative nursing care and patient counseling and teaching in accordance with agency policy and procedure and accepted standards of practice.
Adheres to infection control and exposure prevention practices as outlined by agency policies and procedures.
The Nurse Case Manager manages the plan of care and services of assigned patients
Ensures that there is coordinated and effective sharing of information amongst and between all disciplines, with contracted service providers and other patient care providers as identified.
Continually evaluates the patient's plan of care for skilled and home health aide services and makes revisions as necessary.
Collaborates with the interprofessional team and community resources and maintains communication related to the patient's response to the plan of care.
Regularly evaluates patient progress toward goals and facilitates discharge planning collaboratively with the patient, family and the physician or dentist.
Documents case conferences with other disciplines/clinical team members, clinical manager, physician or dentist, etc. in accordance with agency policies.
The Nurse Case Manager provides exemplary customer service to all customer contacts.
Treats patients, family members, and caregivers respectfully and courteously.
Treats colleagues with respect, trust and dignity.
Precepts colleagues, including those new to home health practices, and participates in the orientation process when assigned.
Participates in the education of nursing students and serves as role model.
Promotes and educates the public regarding agency services and agency specialty programs.
Participates in the Agency's Community Wellness Program that may include but are not limited to blood pressure, diabetic screenings, health counseling, education and administration of vaccines to community dwelling adults
The Nurse Case Manager contributes to the agency's Quality Improvement (QI) Program.
Participates in the agency 's QI committee activities to enhance home health policies, standards and practices
Identifies areas for improvement within agency processes as well as personal/professional learning needs.
Regularly attends staff meetings, inservices or outside seminars to enhance practice and knowledge.
Meets mandatory inservice and competency requirements as determined by the agency.
Accountability/Responsibility
Can be relied upon to meet requirements of job description, with a minimum of supervision
Communicates schedule changes and need for assistance to manager or appropriate person
Is prompt and attends meetings and programs as expected
Organization/Productivity
Demonstrates an ability to perform job responsibilities in an organized, efficient manner
Prioritizes needs and meets productivity standards for the department
Adaptability
Demonstrates an ability to understand and carry out instructions
Adapts to changing conditions during the work day and in the industry
Remains focused and responds appropriately when under pressure
Documentation
Ability to complete and submit job related/required reports in an accurate, clear, concise and timely manner, assuring that content meets any federal, state, local and agency requirements
Professional Integrity
Demonstrates integrity and sound decision making in all issues related to job
Adheres to standard of confidentiality, discussing patient and agency information only with appropriate personnel in the proper setting
Promotes a positive image of the agency at all times
Attendance
Demonstrates faithfulness in coming to work in accordance with assigned work schedule
Adheres to the Agency's Attendance Policy
Teamwork/Commitment
Functions with an understanding of individual performance and its impact on co-workers
Works cooperatively and assists department and agency co-workers as needed
Volunteers for projects/committees to achieve department and/or agency goals
Interpersonal Skills/Communication
Demonstrates an ability to effectively express self, orally and written
Shows respect and courtesy in interactions
Seeks clarification from appropriate source if communication is not clearly understood
Displays a positive attitude and is resolution oriented
Ambition/Motivation
Demonstrates ability to take initiative and to follow through on responsibilities and projects
Presents ideas effectively and encourages participation by others
Delegates responsibility appropriately and offers support and guidance as necessary
Creativity
Demonstrates innovative ideas and suggests positive approaches to problem solving
Recommends plan for implementation
Personal Appearance
Adheres to Human Resources Dress and Footwear Policy