Home Care Case Manager Visit Nurse
Summary of Position:
The Home Care Case Manager (HCCM) is responsible for the provision and coordination of all components of home care services for patients. The HCCM visit nurse will provide care as ordered by the physician, follow policies, procedures, conditions of participation, and regularly report to their supervisor. The incumbent will facilitate the development and implementation of the plan of care as outlined by the physician. In addition, the incumbent will be responsible for all required documentation related to the care delivered and will communicate pertinent information regarding the patient to all appropriate health care team members.
Nature and Scope:
The HCCM oversees the home care services provided to patients. This position interfaces with all levels of home care staff as is required by the Medicare Conditions of Participation and The Joint Commission.
Qualifications:
- Graduate of an accredited school of nursing
- Current Ohio Registered Nurse license in good standing
- One year clinical experience in acute care setting preferred
- Clinical experience must have occurred within the last three years unless employed currently in home care setting
- If working as a specialist, documentation of the skills and certifications must be provided
- Must be capable of standing, stooping, bending and lifting up to 40 lbs.
- Must be self-directed and able to work with little supervision
- Computer skills preferred
- Home care experience preferred
Accountabilities:
- Demonstrates ability to follow nursing process:
- Provides thorough physical, mental and social assessments to individuals upon admission to home care agency as well as during each home care visit.
- Develops plan of care in coordination with patient, family members, physician and home care team.
- Implements home care services according to plan of care.
- Observes and monitors the clinical and psychosocial status of the patient on an ongoing basis with appropriate intervention.
- Complies with all agency regulations/policies/procedures:
- Submits all documentation timely per policy.
- Submits completed initial admission documentation as per policy.
- Implements home care services according to plan of care.
- Completes and submits patient recertifications per policy.
- Follows agency and governing bodies' standards of practice.
- Demonstrates effective case management skills:
- Coordinates delivery of services of all members of the home care team as designated by POC.
- Communicates all pertinent clinical and psychosocial information to home care team members as indicated. Communicates with all disciplines involved with patient care a minimum of every 62 days and/or at recertification.
- Demonstrates knowledge and utilization of community health nursing and community resources.
- Provides patient/family teaching regarding disease process and prevention, infection control, home safety, medications and side effects, and day-to-day management of the patient in the home setting.
- Directs and supervises the delivery of home care aide services, monitors frequency of visits and ensures care plan compliance.
- Notifies all disciplines, physician and home care agency of discharge and completes discharge summary as per policy.
- Attends all scheduled inservices and staff meetings.
- Strives to maintain/improve home care and clinical education.
- Directs and supervises the activities of the licensed practical nurse.
- Performs case workload review as designated by the supervisor.
- Appropriately arranges time off coverage and communicates this with agency.
- Participates in on-call coverage of the agency. Is responsible for maintaining minimum weekend on-call, holiday or other requirements established by the department.
- Minimum productivity expectation of 20 visits per pay averaged over one quarter.
- If you are a member of a speciality service, your primary accountability for case acceptance is with that speciality.
- You are required to maintain a consistent caseload within that speciality service per pay period.
- Other duties as assigned.