Position Summary: The Case Coordinator/Start of Care RN will provide skilled professional service and case management oversight to a variety of home care patients.

Duties and Responsibilities:

The Case Coordinator/Start if Care RN will focus on performing Start of Care and ongoing case management, and will provide comprehensive handoff, including but not limited to assessment findings and plan of care, to assigned field RN as applicable. The Case Coordinator will remain proficient in all aspects of home care RN job description. Provide admission, case management, and follow-up skilled nursing visits for home health patients, coordinating care with field RN, as applicable. Administer on-going care and case management for each patient, assure necessary follow-up care is scheduled and completed. Confer with physician in developing the initial plan of treatment based on physician's orders and initial patient assessment. Provide hands-on care, management, and evaluation of the care plan and teaching of the patient in accordance with physician orders. Revise plan in consultation with physician based on ongoing assessments and as required by policy/regulation. Identification of patient centered goals and an interdisciplinary team approach to meet those goals, under the direction of the home care physician, with the most efficient use of resources and avoidance of re-hospitalization. Coordinate appropriate care, encompassing various healthcare personnel (such as Physical Therapists, Occupational Therapists, LPNs, Home Health Aides, and external providers). Projection of need for home visits on a weekly basis with consideration of input from interdisciplinary team meetings, appropriate utilization of staff resources (i.e. LPN), and frequency ordered and established in individualized care plan. Conduct weekly progress reports with field RNs, LPNs, and adjunct therapies as indicated. Assure charting is up to date. Report patient care/condition/progress to patient's physician and Clinical Manager on a continuous basis. In coordination with field RN as applicable, discharge patients after consultation with the physician and Clinical Manager, reviewing and completing needed clinical documentation. Review nursing documentation on all patients, including any case conferences, patient contacts, medication order changes, re-certifications, progress updates, and care plan changes. Prepare visit/shift reports, updates/summarizes patient records and confers with other health care disciplines in providing optimum patient care. Provides skilled services to VNSHS patients as evidenced by:
Adherence to infection control practices and all agency policies and procedures. Use of Chronic Disease management and health promotion strategies. Use of Motivational Interviewing Techniques. Use of Telehealth. Utilization of the nursing process to evaluate patient-centered goals related to the physical/psychosocial and environmental assessment, diagnosis, plan, and implementation. Communication and collaboration with the home care physician to maintain physician orders and report patient assessment and clinical course.
Demonstrates OASIS proficiency as evidenced by:
OASIS Walk evaluations with clinical manager. Scores on average of 94% or better in OASIS chart review.
Participates in care management and demonstrates effective and timely communication as
evidenced by:
Attendance in weekly meetings Preparation for and interaction at care management meetings at which RN will be expected to discuss entire case load addressing patients reason for home care and progress towards patient centered goals. Follow up on Care Management and/or interdisciplinary group recommendations. Effective utilization of voice mail, e-mail and messaging program.
Demonstrates timely documentation as evidenced by:
Use of the computer in the home. Availability of OASIS data for review/ coding, etc. within 24 hours of visit; re-visit notes locked for processing within 24hours of visit, and timely discharges and transfers. Completion of clinical documentation daily. Completion of HHA, LPN supervisions Timely requests for insurance authorization. Clear documentation of the patients progress towards goals and response to interventions. Provision of mandated federal and state notices to patients to include, but not limited to, NYS Provision of Care, Home Health Beneficiary Notice and Notice of Medicare Non-Coverage.
The RN Case Coordinator oversees an average case load of 50 patients and will primarily work Monday to Friday, but is available to work occasionally on weekends and/or holidays if needed (at least one being a major holiday) per year. Performs at or above the state and national benchmarks for publicly reported key performance indicators. Demonstrates commitment to the team and VNSHS as evidenced by:
Support and promotion of the mission of VNSHS. Representation of the agency in a professional manner. Adherence to VNSHS uniform policy. Flexibility in scheduling with a focus on meeting patient needs. Participation in continuing education (minimum of 3 hours per calendar year), including attendance at annual competency and all mandatory in-services. Attendance at team meetings. Participation in orientation of clinical staff as needed. Participation in orientation of students assigned through educational affiliations between VNSHS and local colleges and universities.
Employee adheres to all applicable federal, state, local laws and regulations as relate to Conditions of Participation of Certified Home Health Agency and/or Certified Hospice. Other duties as assigned.

Qualifications:
New York State license and current registration as a registered nurse.
Able to comply with the New York State regulatory requirements to provide patient careAble to comply with all VNSHS policies, procedures and standards of conduct.Previous experience as an RN.Flexible and able to work well with others as well as function autonomously
techniques of therapeutic communicationAble to facilitate cooperation and communication among team members
RN licensure with current registration to practice as a Registered Professional Nurse in New York State.Baccalaureate degree or higher in Nursing or related field preferred