Registered Nurse Case Manager

4 days ago


Oakland, California, United States Pathways Home Health, Hospice and Private Duty Full time
Job Summary

Pathways Home Health, Hospice and Private Duty is seeking a skilled Registered Nurse Case Manager to join our team. As a Hospice Nurse Case Manager, you will be responsible for admitting patients to our service, assessing their physical, psychosocial, environmental, safety, and developmental needs, and developing an individualized plan of care.

Key Responsibilities
  • Perform initial comprehensive assessments of patients and their families.
  • Document observations, clinical findings, problems, skilled interventions, goals, and discharge plans.
  • Initiate and regularly re-evaluate and revise plan of care in consultation with the assigned Clinical Team Manager.
  • Assess the need for services of other team members (PT, OT, ST, MSW, and HHA).
  • Provide and document skilled care on all visits, including skilled observation of the patient's condition, skilled care, and procedures, and teaching of the patient and/or family.
  • Obtain and document physician orders.
  • Perform Home Health Aide supervisory visits per regulatory requirements.
  • Coordinate care with the assigned Clinical Team Manager, physician, and other members of the home care team, informing them of significant changes in the patient's condition and needs.
  • Follow established standards for point of service technology, documentation, and synchronization.
  • Submit weekly visit schedule of assigned patients and collaborate with Clinical Team Manager to address scheduling needs.
  • Perform re-certifications, resumption of care, transfers, and discharges as requested by the assigned Clinical Team Manager and complete and submit all related documentation.
  • Attend and actively participate in the clinical team multidisciplinary patient conference.
  • Demonstrate established clinical competencies.
  • Participate in agency-sponsored in-service education.
  • Participate in quality improvement activities.
  • Assist in development of agency protocols, procedures, and policies as requested.
  • Assess, develop, organize, and deliver teaching materials for assigned home care patients as appropriate.
Requirements
  • Current California RN license.
  • Minimum of one year of nursing experience required.
  • Current CPR Certificate.
  • Current California driver's license and automobile insurance.


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