Bachelor’s Degree preferred; Associate’s Degree or Diploma in Nursing minimum. New Mexico RN License required. Minimum three years acute care experience required and hospice or home care experience preferred.. Basic typing competency Need to have current driver’s license as well as auto insurance.
Responsible for case management of Home Healthcare patients. Ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state. Responsible o rdevelopment, coordination and scheduling delivery of care through a multidisciplinary team to the patient in the home or community setting. The Case Manager assures completeness, timeliness and appropriateness of the patient care plan, its implementation and ongoing evaluation. Assures communication with the multidisciplinary team, support services and community resources to ensure that care goals are achieved in the most efficient and cost effective manner possible. Ensures that documentation is timely, accurate, complete and reimbursable. Is a patient advocate. Precepts newly hired nurses. .
PRN staff will not be responsible for managing a caseload; but all staff are required to manage the case load, follow up and communication for their daily assignments
Key job accountability # 1 · Demonstrates nursing care management of patients as evidence by
a. Assessments that are complete, timely, and appropriate of physical, mental, psychological/social (behavioral), functional, financial, treatment, resource and spiritual needs of patients.
2.Analysis that defines problems that are capable of correction through home healthcare and hospice interventions and are prioritized in development of care plan.
3.Intervenes consistently with orders and changes interventions with orders to meet changes in patient need
Evaluates each visit the effectiveness of interventions and the patient’s response to intervention
Key job accountability # 2 Provide direct patient care by assessing patient for care needs, resources to meet needs and developing a home care or hospice plan of care in conjunction with physician. Assures completion of required OASIS assessments according to regulations for home care and QAPI measures for hospice
Key job accountability # 3 Coordinates implementation of the plan of care through a multidisciplinary home care or hospice team, community resources and the physician
Key job accountability # 4 Ensures plan of care is followed and that documentation complies with regulation
Key job accountability # 5 Maintains a department productivity standard for visits and caseload management
Key job accountability # 6 Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration, and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met
Key job accountability # 7 Assure patients on case load are notified timely of their visits and of any unplanned schedule changes accommodating, when possible, patent preferences for time of day.
Precepts newly hired nurses, and students and serves as a resource person and professional role model as needed
Key job accountability # 8 Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and assures that changes are communicated timely to the team
Key job accountability # 9 Initiates documentation in the home and completely records all care delivery so that receiving “staff” have record of care delivered by the end of each day which includes admissions
Key job accountability # 10 Demonstrates proficiency and competency in interventions (treatments) required through day to day practice and annual competency testing
Key job accountability # 11 Delegate or assign aspects of patient care to health care team members commensurate with their validated competency to perform the task
Key job accountability # 12 Be professionally responsible for current nursing research, current nursing standards, home care or hospice philosophy in order to maintain quality
Key job accountability # 13 Be responsible for clinical supervision of licensed and non-licensed assistive personnel
Key job accountability # 14 Participates in agency continuous quality improvement activities as required
Key job accountability # 15 Assume other leadership roles as required by the department
Key job accountability # 16 Responsible for weekend and holiday coverage and evening call for agency and patient home visits as required on a rotating basis
Key job accountability # 17 Assure clinical outcomes are met and sustained
Key job accountability # 18 Performs other functions as required