RN Case Manager, Home Health

RN Case Manager, Home Health Palm Coast Responsibilities:

• Conduct comprehensive nursing assessments of patients' physical, emotional, psychosocial, and spiritual needs during admission, resumption of care, recertification, and discharge.
• Develop, implement, revise, and evaluate individualized Plans of Care in collaboration with patients, families, physicians, and the interdisciplinary team (IDT).
• Deliver direct skilled nursing care, including wound care, medication administration and management, IV therapy, injections, symptom management, and patient/caregiver education.
• Perform accurate and timely OASIS assessments to ensure proper reimbursement, quality reporting, and optimal patient outcomes.
• Educate patients and their families/caregivers on disease management, medication adherence, safety measures, self-care techniques, and strategies to prevent re-hospitalizations and promote independence.
• Supervise and direct LPNs/LVNs, home health aides, and other support staff to ensure coordinated, high-quality care delivery.
• Monitor patient progress, promptly identify changes in condition, and adjust care plans accordingly to optimize outcomes.
• Maintain accurate, timely clinical documentation in the Electronic Medical Record (EMR) system in compliance with agency policies, OASIS guidelines, and all regulatory/payer requirements.
• Actively participate in case conferences, interdisciplinary team meetings, and quality improvement initiatives.
• Manage a productive caseload with efficient visit scheduling within the assigned territory while ensuring continuity of care and exceptional patient experience.
• Respond to urgent patient needs and participate in on-call rotations as required.

• Must be RN
• Must have HH Leadership experience
• Must have OASIS experience with HCHB experience preferable
• Main point of contact for field clinicians
• Some Duties Include: Coaching and mentorship of clinicians, responsible for episode of care for patients, order approvals, facilitate case conference, Prep/perform utilization management review, review clinical notes, etc.
• Does have a team of clinicians reporting directly to them
• Graduate from an approved school of professional nursing and currently licensed to practice as a registered nurse in the state of agency operation.
• One (1) year experience as a RN.

• Licensed to practice as a registered nurse in the state of agency operation.
• Must possess and maintain valid CPR certification while employed in a clinical role.
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order. Ability to travel to all business locations.