RN-Case Manager, Post Acute
Coordinates patients' interdisciplinary plan of care through assessment and evaluation of patient condition and effectiveness of care under the direction of the attending physician by traveling to patient homes, Community-Based Residential Facilities (CBRF), assisted living locations, hospitals or other to meet patient and family/caregivers, assess patient care needs, acuity in relation to regulations of home care and/or hospice services.
* Collaborates with the patient, family and healthcare team to develop a comprehensive plan of care based on the unique needs of the patient. Responds to calls from patients, family members and others, completes follow-up to address needs, issues, or concerns.
* Provide skilled nursing care within the established plan of care, including performance of tasks such as taking vitals, performing wound care, IV care, ostomy care, blood draws, injections, and the physical assessment of the overall patient's medical condition. Conducts patient admissions and routine visits.
* Continually evaluates the patient's condition and the effectiveness of treatments, plan of care, medications, and therapies. Reviews, sets-up, and administers medications as necessary per the established plan of care.
* Documents visit notes, treatments, and care. Follows visit pattern according to physicians orders and ensures required visits are completed in a timely manner. Ensures all documentation is timely, accurate and complete in adherence to regulations.
* Collaborates, consults and communicates with physician regarding the plan of care and changes to patient status. Provides physician with regular updates on progress and recommends revision of plan care, documents status and communication in adherence with regulations.
* Coordinates and communication with multi-disciplinary team members and outside agencies as appropriate to achieve expected outcomes for patient care and education through end o