Job Title: Home Health RN Case Manager

Job Summary:

The Home Health RN Case Manager provides skilled nursing care to patients in their homes and acts as the main point of contact for coordinating services with other healthcare professionals. The RN Case Manager is responsible for assessing patient needs, developing individualized care plans, managing clinical staff, and ensuring that care is provided according to established protocols and patient goals.


Key Responsibilities:
1. Patient Assessment:
• Perform initial and ongoing assessments of patients in their home environment.
• Evaluate the physical, emotional, and social needs of patients to develop care plans.
2. Care Plan Development and Implementation:
• Develop and continuously update individualized care plans based on the patient's specific conditions and needs.
• Coordinate care with interdisciplinary teams including physicians, therapists, and other healthcare providers.
• Provide patient education and family support to ensure proper care management.
3. Clinical Care:
• Provide skilled nursing services, including wound care, medication administration, IV therapy, and other necessary clinical tasks.
• Monitor patient progress and adjust care plans as needed.
4. Case Management:
• Act as the primary point of contact for patients, families, and healthcare providers.
• Manage a caseload of patients and ensure they receive timely and appropriate services.
• Ensure compliance with state and federal home health regulations.
5. Coordination of Care:
• Communicate regularly with physicians, physical/occupational therapists, social workers, and other members of the care team to coordinate care.
• Facilitate referrals to other services as needed (e.g., specialist visits, physical therapy).
6. Documentation:
• Maintain accurate, up-to-date medical records, including patient progress, assessments, and any changes to care plans.
• Ensure timely submission of required documentation in compliance with healthcare regulations.
7. Patient Advocacy:
• Advocate for patient needs and preferences, ensuring they are respected in the care plan.
• Support patients and families in navigating the healthcare system, addressing concerns, and accessing community resources.
8. Compliance:
• Stay current with best practices and regulations for home health care.
• Ensure care delivery meets agency policies, Medicare/Medicaid standards, and other relevant regulations.

Qualifications:
• Education:
• Bachelor's degree in Nursing (BSN) preferred, Associate's degree in Nursing (ADN) accepted.
• Licensure:
• Active and unencumbered Registered Nurse (RN) license in the state of practice.
• Experience:
• At least 1-2 years of clinical nursing experience, preferably in home health, hospice, or a related field.
• Case management experience preferred.
• Certifications:
• Basic Life Support (BLS) certification required.
• Certification in case management (e.g., CCM) is a plus.

Skills and Abilities:
• Strong clinical nursing skills and the ability to work independently.
• Excellent communication and interpersonal skills.
• Strong organizational and time management abilities.
• Ability to handle a caseload of patients while ensuring high-quality care.
• Familiarity with electronic medical records (EMRs) and home health care software.

Working Conditions:
• Ability to travel to patient homes and work in a variety of home environments.
• Must have a valid driver's license and reliable transportation.
• Ability to work independently while managing multiple patients.
This job description can vary based on the specific employer, location, and the level of responsibility assigned to the RN Case Manager role.