Job Description

Position Summary

The RN Field Case Manager is accountable to the Director of Professional Services and Clinical Manager for providing exceptional nursing care and case management to patients and their families. The RN Field Case Manager is responsible for the initial and ongoing comprehensive assessment of the patient, including the Start of Care (SOC), Resumption of Care (ROC), Recertification, Transfer, and Discharge OASIS assessments as required. This role involves implementing nursing interventions and coordinating interdisciplinary plans of care while supervising personnel to ensure effective care delivery. The RN Field Case Manager provides high-quality and compassionate care that is within the nurse’s education and experience and in accordance with physician orders, agency policies, regulatory and accreditation requirements. This role supports the delivery of safe, goal-oriented patient care, promotes positive relationships with patients and families, and contributes to the overall growth and success of the organization.

General Responsibilities

• Manage a patient caseload by assessing, planning, implementing, evaluating, and documenting the care provided.
• Contribute to company profitability by effectively utilizing resources and promoting services to the community.
• Assist in creating and executing achievable, goal-oriented care plans.
• Participate in ongoing evaluations of patient responses to treatment under the supervision of management.
• Provide individualized health education and self-care instruction as directed.
• Maintain liaison between the patient, family, physician, and agency staff to ensure continuity of care.
• Accurately document and electronically submit all required clinical records, including OASIS, visit notes, supervisory notes, and communication logs, within agency-specified timelines (within 24–48 hours).
• Assist in onboarding and training new employees as needed.
• Serve as a communication link between the organization and patients.
• Foster a safe and supportive care setting that aligns with patient goals.
• Work effectively with healthcare team members, patients, and families.
• Complete and submit documentation in a clear and timely manner according to agency policies.
• Supervise and document care plans for home health aides and licensed practical nurses, including supervisory visit documentation.
• Participate in on-call coverage as required.
• Performs other duties as assigned

Essential Job Responsibilities

Patient Care & Clinical Duties

• Reviews and updates the plan of care in coordination with the physician and interdisciplinary team at least every 60 days or upon significant change in condition.
• Contribute to developing and implementing individualized, goal-oriented plans of care.
• Conducts initial and ongoing comprehensive assessments, including OASIS evaluations.
• Develop comprehensive discharge plans based on interdisciplinary input
• Determines scope and frequency of services needed based on acuity and patient/family needs
• Perform ongoing patient assessments and report changes in condition to the supervising Clinical Manager. Informs the physician and other personnel of changes in the patient’s needs and outcomes of intervention.
• Administer medications and treatments in accordance with physician orders and established protocols, maintaining strict aseptic technique.
• Assist patients with prescribed exercises, ambulation, and transfers, including full patient transfers when necessary, using proper body mechanics.
• Provide patient and family education on self-care techniques, treatments, and health management.
• Participate in interdisciplinary team meetings to coordinate care, problem-solve, and receive support and education.
• Participates in ongoing in-service training and quality assessment performance improvement (QAPI) as requested by the office.
• Uses case management approach and refers to other services as needed.
• Conducts supervisory visits for home health aides at least every 14 days and for LPNs as per agency policy and regulatory requirements.
• Participates in QAPI activities, providing feedback related to clinical outcomes, infection control, and patient satisfaction data.

Compliance, Safety & Patient Rights

• Adhere to agency policies, accreditation standards and federal/state regulations.
• Protect patient confidentiality and ensure compliance with HIPAA.
• Promote patient rights, reporting any concerns, complaints, or allegations of abuse/neglect immediately.
• Follow infection control protocols, including standard precautions and CDC hand hygiene guidelines.
• Identify and respond appropriately to emergencies and report accidents/incidents promptly.
• Maintain a safe and therapeutic environment for patients.
• Immediately reports any suspected or verified abuse, neglect, or exploitation in accordance with state law and agency policy

Professionalism & Teamwork

• Demonstrate collaborative relationships with patients, families, and healthcare colleagues.
• Assist in orienting and mentoring new staff, as requested.
• Maintain clinical competency by seeking ongoing professional development.
• Exhibit professionalism, accountability, and a positive attitude, serving as a role model for teamwork and problem-solving.

POSITION DESCRIPTION

Administrative & Organizational Responsibilities

• Ensure accurate and timely completion of documentation required for clinical, compliance, and billing purposes.
• Collaborate with contracted service providers and community health resources as needed.
• Manage time effectively to meet productivity standards while ensuring quality care delivery.
• Support the mission of the agency through appropriate use of resources and by representing the company positively in the community.

Qualifications | Experience | Education

• Current, active RN license in the state of practice and in good standing
• Strong knowledge of OASIS home health regulations
• One year of clinical nursing experience preferred (home health experience desirable).
• Strong communication and documentation skills.
• Ability to work collaboratively as part of a healthcare team.
• Commitment to patient-centered, safe, and compassionate care.
• Current CPR certification
• Valid driver’s license, auto insurance, and reliable transportation

Work Environment Considerations

This position operates in patient care environments, which may include private homes, assisted living facilities, or clinical settings. The role involves frequent standing, walking, bending, reaching, and occasional lifting or transferring of patients using proper body mechanics and assistive devices as needed. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Essential physical tasks include the ability to:

• Safely lift, carry, push, or pull up to 35 pounds.
• Assist with patient transfers and ambulation.
• Tolerate prolonged periods of physical activity, including standing and walking.
• Respond quickly in emergency situations.
• Travel throughout the service area on a daily basis to visit patients/clients.
• Participate in on-call coverage as required.

OSHA Category 1 – Tasks involve routine exposure to blood, body fluids, communicable diseases or other potentially infectious materials. Must follow universal precautions, infection control procedures and personal protective equipment (PPE) are required.

Acknowledgement

I have reviewed and understand the duties, responsibilities, and expectations outlined in this job description. I acknowledge that this document is not a contract of employment and that the responsibilities described may change over time based on organizational needs. I understand that I may be required to perform other duties as assigned and that this description will be reviewed and updated as needed.