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Registered Nurse -Case Manager, Home Health, Full time, Daytona - Home Health

Company: Halifax Health Medical Center of Daytona Beach
Location: Daytona Beach
Posted on: January 20, 2023

Job Description:

Registered Nurse -Case Manager, Home Health, Full time, DaytonaResponsibilities

* Initiates the Brooks Home Care experience by representing self as the Brooks Home Care Case Manager to patient and family. The RN Case Manager explains the clinical case manager role and process to the patient and family should contact clinical case manager for all coordination of home health services and needs.
* Provides initial assessment of the patient and the family for appropriateness and acceptance of home health care services, establishment and ongoing review of the plan of care, implementation of medical treatment orders, referral, follow-up, provision and supervision of nursing care, coordination of services given by other health care providers, and documentation of all activities and findings.
* Responsible for ensuring that all assessments and the plan of care is up to date, reflect current status, and needs of the patient throughout the care of the patient.
* Serves as a health care educator by teaching and training patients and caregivers regarding the identified health care needs.
* Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions, including the patient and/or family's home health goals into the overall plan of care.
* Responsible for maintaining a concurrent medical record using specific standards of practice and agency guidelines.
* Provides and coordinates skilled nursing care as outlined in the nursing care plan to include pertinent signs and symptoms while also reporting significant changes to the physician including revisions to treatments, drugs, and changes in the patient's physical and emotional condition.
* Evaluates every patient for additional home health services to include skilled therapy (PT, OT, SLP, RT), HH Aide and other ancillary services.
* Refers cases where patients and/or family would benefit from counseling and/or community resources required to enhance the overall plan of care and meet the patients and caregivers needs for appropriate discharge planning to social worker.
* Direct oversight and review of changes in the patient's condition and/or family and home situation, makes revision in the plan of care as needed, and notifying the physician of patient's condition and progression at least every 60 days.
* Completes an updated OASIS when Significant Changes in Condition occurs.
* Communicates with physicians and other health care providers throughout the home care treatment and develops an effective working relationship.
* Supervises, evaluates, and verifies care given by home health aide follows the plan of care as written. Updates the home health aide Plan of Care as the needs of the patient changes and ensures home health aide operates according to policy and regulations. Supervisory visits conducted every 14 days.
* Supervises and evaluates the care given by the LPN every 30 days or more frequently if necessary.
* Facilitates interdisciplinary patient care conferences to review treatment goals, optimize resource utilization, provide family education, and identified post-hospital needs.
* Promote effective and efficient utilization of clinical resources and services from admission through discharge.
* Evaluate patient satisfaction and quality of care provided.
* Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery.
* Participates in clinical record reviews, staff meetings, and in-services as needed.
* Serves as a mentor and preceptor for nurses and other home health clinicians.
* Serves as the RN on-call Nurse as scheduled on a rotating basis.
* Serves as the visiting Weekend RN Nurse as scheduled on a rotating basis.
* RN should be able to accept additional patients beyond their normal work schedule as needed.
* Actively supports the established Brooks organizational values (Innovation, Integrity, Teamwork, Service, Excellence, and Accountability) as evidenced by behavior and job performance.


* Current licensed Registered Nurse in the state of Florida.
* Associate, Bachelors, or Master's degree from an approved school of Nursing.
* One-year recent nursing experience required.
* Prefer at least one-year's home health, Acute Care or adult health nursing experience.
* Must be a licensed driver with an insured automobile in accordance with requirements.
* TB skin test or chest X-ray as proof of freedom from TB every year.
* Current CPR certificate. Hands-on BLS certification.
* Maintains BLS certification and assumes responsibility for maintaining required continuing education and unit specific credentials.
* Will consider sponsorship. Must have:
* 2 years' applicable experience
* Current Florida Nursing license or evidence of having passed NCLEX Exam
* English proficiency

Keywords: Halifax Health Medical Center of Daytona Beach, Daytona Beach , Registered Nurse -Case Manager, Home Health, Full time, Daytona - Home Health, Executive , Daytona Beach, Florida

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