RN Case Manager

Position Summary

The Registered Nurse Case Manager is responsible for coordinating and managing the overall care of an assigned caseload of home health patients.

The RN Case Manager performs comprehensive patient assessments, develops and updates individualized plans of care, provides skilled nursing services as ordered, coordinates services with physicians and other members of the interdisciplinary team, and monitors patient progress and outcomes.

The ideal candidate will have strong clinical judgment, excellent communication skills, and experience providing nursing care in a home health setting.

Key Responsibilities

Patient Assessment & Clinical Care

• Perform comprehensive nursing assessments of patients in their homes.
• Assess patient condition, medical history, medications, functional status, and safety needs.
• Identify changes in patient condition and respond appropriately.
• Provide skilled nursing services in accordance with physician orders and the individualized plan of care.
• Monitor patient progress toward established goals.
• Identify potential complications and take appropriate action.
• Educate patients and caregivers regarding medications, disease processes, treatments, safety, and self-management.
• Promote patient independence and appropriate disease-management strategies.
• Provide appropriate interventions based on patient needs and established plan of care.

Case Management & Care Coordination

• Manage an assigned caseload of home health patients.
• Develop, implement, and regularly update individualized plans of care.
• Coordinate services among patients, families, physicians, nurses, therapists, home health aides, social workers, and other healthcare providers.
• Communicate changes in patient condition to the appropriate healthcare professionals.
• Follow up on physician orders and recommendations.
• Coordinate admissions, recertifications, resumptions of care, transfers, and discharges as applicable.
• Participate in interdisciplinary case conferences and care planning.
• Assist patients and families in accessing appropriate healthcare resources.

OASIS & Clinical Documentation

• Complete OASIS assessments and required reassessments accurately and within agency-established timeframes.
• Complete admission, recertification, resumption of care, transfer, discharge, and other required clinical documentation.
• Maintain accurate, timely, and complete clinical records.
• Document patient assessments, interventions, response to treatment, and progress toward goals.
• Ensure documentation supports the patient's plan of care and services provided.
• Communicate documentation concerns or clinical issues to the Clinical Director/DON.
• Utilize the agency's EHR/EMR system, including Alora Plus or comparable home health software.

Physician & Interdisciplinary Communication

• Communicate effectively with physicians and other healthcare providers.
• Obtain and follow physician orders appropriately.
• Notify physicians and agency leadership of significant changes in patient condition.
• Coordinate care with physical therapy, occupational therapy, speech therapy, medical social services, home health aides, and other disciplines.
• Participate in care conferences and interdisciplinary coordination.
• Promote continuity of care across the healthcare team.

Patient & Family Education

• Educate patients and caregivers regarding diagnoses, medications, treatments, nutrition, safety, and disease management.
• Teach patients and caregivers appropriate home-care techniques.
• Reinforce medication adherence and treatment plans.
• Identify barriers to care and work with the patient and healthcare team to address them.
• Provide compassionate support to patients and families throughout the episode of care.

Quality & Compliance

• Provide care consistent with Medicare, Medicaid, Indiana requirements, physician orders, and agency policies.
• Follow applicable professional nursing standards and agency procedures.
• Participate in quality assurance and performance improvement activities.
• Monitor patient outcomes and identify opportunities to improve care.
• Follow infection prevention and patient-safety practices.
• Maintain patient confidentiality and comply with HIPAA requirements.
• Participate in agency audits, education, and quality initiatives as requested.

Home Health Aide Coordination

• Collaborate with the Clinical Director/DON and home health aides regarding patient needs.
• Ensure home health aide services are consistent with the patient's plan of care.
• Provide appropriate instructions and communicate changes in patient needs.
• Monitor patient response to services and report concerns appropriately.

Qualifications

Required

• Current, unrestricted Registered Nurse (RN) license in the State of Indiana.
• Graduate of an accredited nursing program.
• Previous clinical nursing experience.
• Strong assessment and critical-thinking skills.
• Excellent written and verbal communication skills.
• Strong organizational and time-management abilities.
• Ability to work independently in patients' homes.
• Ability to manage multiple patients and priorities.
• Reliable transportation and ability to travel to patient homes.
• Valid driver's license and appropriate automobile insurance.
• Proficiency with EHR/EMR systems, including Alora Plus or comparable home health software.
• Previous home health nursing or case management experience.
• Experience working in a Medicare- and Medicaid-certified home health agency.
• Experience with OASIS.
• Experience with home health documentation and plans of care.
• Knowledge of Medicare and Medicaid home health requirements.
• Experience coordinating interdisciplinary care.
• BSN preferred.
• Previous experience as a Home Health RN Case Manager.

Pay: $70,000.00 - $75,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Flexible schedule
• Health insurance
• Life insurance
• Vision insurance

Education:

• Master's (Preferred)

Work Location: In person