RN - CASE MANAGER

The registered nurse plans, organizes and directs/coordinates home care services and is experienced in nursing, with emphasis on community health education/experience.  The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

DUTIES & RESPONSIBILITIES

Patient Care

• Develops and initiates the plan of care and assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s);
• Initiates proper preventative and rehabilitative nursing procedures and provides services that are ordered by the physician as indicated in the plan of care;
• Provides patient, caregiver, and family counseling;
• Provides patient and caregiver education;
• Prepares clinical notes; 
• Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care.

• Prepares clinical notes and updates the primary physician when necessary and at least every sixty days.

   

• Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.

   

• Communicates with community health related persons to coordinate the care plan.