Job Description

The RN Case Manager is responsible for completing initial and ongoing nursing assessments, supervising Home Health Aides/PCAs, developing and updating individualized care plans, and ensuring safe, high-quality care for clients receiving non-skilled home care services.

This position focuses on assessment, evaluation, education, and regulatory compliance — not hands-on skilled nursing procedures.

Essential Functions

Initial & Ongoing Assessments

• Conduct initial in-home assessments for all new clients, including evaluation of:
  • Medical/functional history as it relates to the care plan
  • ADLs, cognition, safety, home environment
  • Risks, equipment needs, caregiver support, and overall ability to remain safely at home
• Complete 90-day, 6-month, and annual reassessments per DOH and payer requirements.
• Identify any changes in condition and coordinate follow-up with appropriate providers or care managers.
• Determine the need for Home Health Aide/PCA services and the appropriate frequency/scope of tasks.

Care Planning & Oversight

• Develop and maintain an individualized Plan of Care (POC) aligned with the patient's needs, goals, and authorized services.
• Update care plans whenever the patient’s condition or needs change.
• Educate patients and caregivers regarding safe home care practices, disease awareness, ADLs, emergency planning, and community resources.

Supervision of Home Health Aides / PCAs

• Conduct supervisory visits in the patient’s home to evaluate:
  • Quality of aide performance
  • Compliance with the care plan
  • Patient satisfaction and safety
• Provide coaching, teaching, and corrective guidance to PCAs/HHAs as needed.
• Document all supervisory contacts in accordance with DOH requirements.

Coordination & Communication

• Communicate with service coordinators, schedulers, MLTC care managers, physicians’ offices, and family members to ensure seamless care delivery.
• Report significant changes in condition promptly to appropriate parties.
• Participate in case reviews and quality improvement initiatives.

Documentation & Compliance

• Complete accurate, timely electronic documentation in accordance with DOH, Medicaid, MLTC, and agency standards.
• Maintain knowledge of New York State LHCSA regulations, infection control requirements, and payer guidelines.
• Ensure all care delivery is compliant with the care plan, authorized tasks, and scope-of-practice restrictions for LHCSAs.

Requirements

Education Requirements

• Associate Degree in Nursing (ASN) required
• Bachelor of Science in Nursing (BSN) preferred

Qualifications & Requirements

• Active New York State Registered Nurse (RN) license.
• Experience in home care, community health, case management, or related setting preferred (LHCSA experience ideal).
• Strong assessment, communication, and documentation skills.
• Knowledge of LHCSA regulations, MLTC requirements, care plan development, and supervision standards.
• Valid NYS driver's license and reliable transportation.
• Ability to work independently, manage a field-based schedule, and maintain professionalism in varied home environments.

Work Environment

• Field-based role; requires travel to client homes throughout Monroe and the surrounding Counties.
• Must be able to perform activities including standing, sitting, walking, bending, and light lifting related to home visits and evaluations.

Equal Opportunity Employer

We welcome applicants from diverse backgrounds and do not discriminate based on race, color, religion, sex, gender identity, disability, veteran status, or national origin.