RN Case Manager

Initiate, develop, and implement the patient Plan of Care (POC), revising it as needed with the patient, physician, and team. Establish patient-specific goals while incorporating therapeutic, preventative, and rehabilitative nursing services. Oversee and deliver quality, patient-centered care in the patient's home or living facility. Communicate necessary revisions regarding patient status, needs, and discharge planning to the entire care team. Regularly consult with patients, families, and representatives to reevaluate safety, plan, and outcomes. Provide complete, accurate, and timely documentation consistent with the plan of care. Drive to patient homes for visits.