Position Summary

The Home Health RN Case Manager is responsible for coordinating and delivering skilled nursing care to patients in their homes. This position manages a caseload of patients, develops individualized plans of care, performs comprehensive assessments, coordinates interdisciplinary services, and ensures compliance with physician orders, agency policies, and regulatory requirements.

Essential Duties and Responsibilities

Patient Care

• Perform comprehensive patient assessments and develop individualized plans of care.
• Complete Start of Care (SOC), Resumption of Care (ROC), Recertification, Transfer, and Discharge assessments.
• Provide skilled nursing care in accordance with physician orders and agency policies.
• Monitor patient progress and update care plans as needed.
• Assess physical, emotional, psychosocial, and environmental needs of patients.
• Administer medications and treatments as ordered.
• Perform wound care, catheter care, infusion therapy, and other skilled nursing procedures.
• Identify changes in patient condition and communicate findings to physicians and appropriate care team members.

Case Management

• Manage an assigned caseload of home health patients.
• Coordinate care among physicians, therapists, social workers, home health aides, and other healthcare providers.
• Ensure timely scheduling and completion of visits.
• Facilitate appropriate utilization of resources and services.
• Participate in case conferences and interdisciplinary team meetings.
• Monitor patient outcomes and work to reduce hospital readmissions.

Documentation & Compliance

• Complete all documentation accurately and timely within the EMR system.
• Ensure compliance with Medicare, Medicaid, state, federal, and accreditation requirements.
• Maintain accurate patient records and care plans.
• Complete OASIS assessments and documentation as required.
• Adhere to HIPAA and patient confidentiality requirements.

Patient & Family Education

• Educate patients and caregivers regarding disease processes, medications, safety precautions, and self-management techniques.
• Provide instruction on equipment use and home safety.
• Promote patient independence and achievement of healthcare goals.

Qualifications

Required

• Current Registered Nurse (RN) license in the applicable state.
• Graduate of an accredited school of nursing.
• Minimum of one (1) year of nursing experience.
• Valid driver's license, reliable transportation, and current auto insurance.
• Ability to travel throughout assigned service area.
• Strong assessment, organizational, and communication skills.
• Basic computer and EMR proficiency.