Registered Nurse Case Manager, Level 2
On-siteSebastopol, California, United States
Job Summary
Create, implement, and execute the overall plan of care to promote wellness and prevent re-hospitalization for patients in their homes. Conduct comprehensive patient assessments including Start of Cares, Evaluations, discharge planning, and initial visits. Provide one-on-one assistance and teaching to patients and families regarding wound care, blood draws, tube feedings, tracheostomy care, foley catheters, CHF management, and medication education. Supervise two nurses responsible for executing the care plan while collaborating with physicians and interdisciplinary teams. Prepare clinical notes, orders, and compliant charting within required timeframes. Visit patients in Sebastopol and surrounding areas to achieve improvement or stability.
Required Qualifications
- One Year of Home Health Case Management experience
- Minimum of one year of Nursing Experience
- Current and unrestricted CA RN license
- Current BLS/CPR Certification
- Valid CA Driver's License
- High level of clinical knowledge in home health care
- Experience working with an interdisciplinary team
- Case Management fundamentals
- Self-Directed
- Empathetic
- Critical thinker
- Outstanding interpersonal skills
- Leadership skills
- Organized
- Must be available for field visits visiting patients in their homes
- Must be able to supervise, mentor Nurses
- Must be able to create, implement and execute the overall plan of care
- Must be able to conduct comprehensive patient assessments such as Start of Cares (SOCs), Evaluations, Resumption of Care and discharge planning
- Must be able to perform a full assessment of the patient & family upon initial visit
- Must be able to use assessment data to develop an advanced plan of care including rehabilitation
- Must be able to work with patients and family one on one to achieve improvement and/or stability
- Must be able to case manage patients care episode with interdisciplinary clinical team
- Must be able to prepare clinical notes, orders and charting in a compliant time frame
- Must be able to collaborate with physicians and agency staff to deliver the best care possible
- Must be able to provide assistance and teaching of patients' and their family/caregivers with wound care, blood draws, tube feedings, Tracheostomy care, foley catheters, Congestive Heart Failure (CHF) management and medication education
Desired Qualifications
- One Year of Home Health Case Management experience
- Two+ years of Nursing Experience
- Experience supervising, mentoring Nurses
- Experience with high acuity patients
- Experience working with an interdisciplinary team
- Case Management fundamentals
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