Registered Nurse Case Manager, Level 2
On-siteNovato, California, United States
Job Summary
Create and execute comprehensive plans of care to promote patient wellness and prevent re-hospitalization in home settings. Conduct assessments including Start of Cares, evaluations, and discharge planning while overseeing two nurses responsible for care execution. Provide one-on-one instruction to patients and families regarding wound care, blood draws, tube feedings, tracheostomy care, and medication management. Collaborate with physicians and interdisciplinary teams to manage high-acuity cases and prepare clinical documentation within compliant timeframes. Visit patients in Novato and surrounding areas to achieve care stability and improvement.
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 visiting patients in their homes
- Must be able to supervise, mentor Nurses
- 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 oversight of 2 Nurses who are responsible for executing the care plan
- Must be able to assist and teach 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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