RN Case Manager

RN Case Manager

The Registered Nurse Care Manager (RN) works collaboratively as part of a care management team to assess consumer needs, establish a person-centric plan of care, conduct regularly scheduled home visits. The RN coaches, advocates and educates caregivers to assist with the daily health and well-being needs of consumers.
• Completes and coordinates all applicable clinical assessments and clinical evaluations
• Trains, evaluates and supports Caregivers in conjunction with the care manager as needed on an on-going basis
• Coordinates consumer placement following acceptance to program and ensures that all required forms and standard procedures are followed for the placement process. Conducts orientation training for each caregiver before the caregiver enters the program as well as on-going training.
• Provide ongoing coaching to drive effective utilization of established best practices and protocols (carepaths) where appropriate
• Works collaboratively to develop and review on an ongoing basis, each member’s plan of care
• Reviews the caregiver notes daily and appropriately addresses changes in the consumer’s condition or environment
• Completes nursing progress note corresponding with each on-site visit or encounter, or more often as the member’s condition warrants
• Submits semi-annual health-status reports to each member’s PCP based on regulatory requirements
• Monitors the health status of all members to ensure that all needed AFC is properly delivered
• Reports changes in health status of any member to the member’s Primary Care Physician
• Coordinates the implementation of physician’s orders with the consumer, caregiver and other team members
• Plans and implements discharges and transition from the AFC program
• Ensures continuous survey readiness and compliance with accepted professional standards and practices and federal/state/local regulations including fraud, waste and abuse prevention; HIPAA and similar regulations; occupational safety and health standards; and company policies, procedures and performance standards.
• Perform other duties as assigned.