Job Summary:
Reports directly to the Home Health/Hospice Manager and responsible for providing skilled nursing care on an intermittent basis to patients in their home and to coordinate all services provided to the patient both by this agency and outside referral sources. The Case Manager acts as a liaison between the patient, family or caregiver and the physician.

Essential Duties and Responsibilities:
• Provides skilled nursing services in accordance with the orders of a physician and under a plan of care in a patient’s home.
• Makes the initial evaluation visit and records the health needs of the patient. Initiates Plan of Care and makes revisions if and when necessary.
• Formulates a nursing care plan based on the patient’s nursing diagnosis.
• Evaluates the effects of the care given and regularly re-evaluates the patient’s nursing needs.
• Performs OASIS assessment for the Home Care and utilizes LCD’s to determine Hospice eligibility.
• Provides services requiring substantial specialized nursing skills based on physician’s orders and nursing diagnosis. Examples of services include, but are not limited to:
  o Physical assessment
  o Patient and family teaching
  o Urinary and catheter in insertion and care
  o Venipuncture and administration of IV fluids or medications
  o Dressing changes, sterile and non-sterile
  o Pain management
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Counsels the patient and the family in meeting needs.
• Acts as coordinator of the health care team in order to maintain the proper linkages to provide the necessary care on a continuing basis.
• Provides summary reports to the patient’s physician about the patient under care when the patient’s condition changes or there are deviations from the plan of care, or at least every 60 days.
• Prepares clinical and progress notes on the relevant and specialized nursing services he/she provides.
• Participates in clinical records reviews.
• Participates in in-service programs and staffing meetings.
• Coordinates the care of all patients in his/her caseload.
• Directs the activities of the Licensed Practical Nurse.
• Makes the home health aide assignment, prepares written instructions for the aide and supervises the aide in the home.
• Attends weekly inter-disciplinary team conference.
• Participates in on-call services for weekends, holidays and evenings on a rotating basis at an additional on-call rate.
• Performs other duties that may be assigned from time to time.

Education & Experience:
1. Graduate of Bachelor’s Degree in Nursing; License is required.
2.  Minimum of 2 years experience and must have impressive track record as Registered Nurse, specifically in providing skilled nursing care on an intermittent basis to patients in their home and to coordinate all services provided to the patient both by this agency and outside referral sources.
3. Must have the appropriate level of behavioral maturity and patience in handling patients.
4. Must have the diplomacy and tact in handling difficult and irate patients.
5. Very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
6.  Outstanding communication skills and persuasiveness, specially the ability to communicate instructions and procedures for treatments, keeping the patients and giving them the desired level of comfort and confidence.
7.  Must have strong sensitivity to the needs and anxieties of patients and the ability to motivate patients to undergo treatments and/or procedures.
8. Strong ethics and a high level of personal and professional integrity.
9. Knowledgeable of federal and state laws and requirements relating to healthcare management.
10. Computer literate and very highly proficient in using MS office programs.