Job Description

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Department: Home Care

Shift/schedule: Full Time (Salaried)

GENERAL SUMMARY

Works under the supervision of the Nurse Manager of Hospice/Home Care Services. The RN Case Manager assumes responsibility for a caseload of patients from admission to discharge. Duties include: admission; revisit; coordination of after hours and overflow visits; developing and modifying the plan of care; coordinating ancillary services e.g. rehabilitation therapists, social worker and home health aide and completion of required documentation including discharge. Monitors fiscal performance of caseload. OASIS data collection at all time points. Performs IV Therapy visits and rotates on-call. Performs field supervision of LPN's and Aides. Responsible for financial performance of caseload and results on OASIS outcomes and clinical process measures. Assists with QAPI program. Participates in holiday visit rotation. Performs other duties as assigned.

QUALIFICATIONS

Education:

• High School Diploma or successful completion of an equivalent High School Exam Required

• Graduate of an accredited school of nursing required

Licensure:

• Licensed to practice as an RN in Ohio required

• Licensed to practice as an RN in Kentucky to be obtained after hire required

• BMVL required (Must maintain eligibility to drive as determined by SOMC insurance carriers)

• BSN preferred

• BLS within 90 days of hire required

Experience:

• One year prior nursing experience in the acute or long term care setting required

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

1. Performs admission visits. Initiates and completes the Physicians Plan of Care in collaboration with the patient, family, physician, and other health care team members. Obtains informed consent for treatment. Informs patients both verbally and in writing of their rights and responsibilities as patients receiving Home Care and reviews the patient grievance procedure. Informs the patient, family or responsible party of available insurance coverage for Home Care services and non-reimbursable services. Provides to the patient, family or responsible party information regarding the patient's rights to formulate Advance Directives. Instructs the patient, family or responsible party of processes to follow if assistance is needed after regular office hours. Reviews with the patient, family or responsible party general emergency preparedness instructions.

2. Uses assessment skills and interviewing techniques to identify patient problems and patient care needs including teaching needs.

3. Completes OASIS assessments on admission and at all designated intervals.

4. Formulates and initiates the plan of care including Home Care discharge planning, in collaboration with the patient, family, and/or caregivers, and other health care team members. Evaluates and revises the plan of care to reflect the current and changing status of patients.

5. Makes home visits to render professional nursing care. Instructs patients and/or caregivers in patient care procedures and determines ability to perform.

6. Completes clinical records for required documentation in accordance with Home Care standards. Maintains confidentiality of patient information.

7. Makes Home Health Aide Supervisory visits in accordance with federal regulations, documents in the clinical record, and communicates changes in patient conditions and revisions in care. Periodic aide observational visits are performed as scheduled for determination of aide competency.

8. Seeks guidance from RN Coder or Intake Staff for appropriate ICD-10 diagnosis coding.

9. Maintains regular and frequent communication with other members of the Home Care team.

10. Conducts field supervision of LPN co-workers

11. Makes visits to SOMC inpatient units and area nursing facilities to visit current patients.

12. Participates in the 24-hour, 7 day a week on-call nursing coverage for patients/families as appropriate.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position in accordance with applicable law. A full job description is available upon request.

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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.