Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a patient’s health needs through communications and available resources to promote cost-effective quality outcomes.

Description:

Provide the outcomes-oriented care and oversight to a given patient caseloads in collaboration with other registered nurses, licensed vocational nurses, home health aides, therapists, physicians and other team members. Responsible for the overall coordination of services provided to patients by the other licensed and under licensed personnel.

JOB DUTIES/ KNOWLEDGE:

• Works closely with scheduler: Field staff on scheduling, to ensure that all patients are assigned and scheduled with appropriate disciplines and frequencies.
• Responsible for receiving all incoming calls from skilled nurses, relatives, physicians, patients and other disciplines.
• Responsible and accountable for following through with all incoming calls and problems through adequate documentation with the use of inter-office communication form/occurrence variance report from when applicable.

Inter-office Communication Form should consist of but not be limited to:

• Patient problems and course of events.
• Physician notification of problems/ including abnormal lab results.
• Orders from physician and physician name.
• Notification of changes to all disciplines involved in patient’s care.
• Change in frequencies.
• Name of patient, MR#, person calling, title, date and time.

• Work closely with scheduler to ensure that all patients are scheduled according to set frequencies; HCA supervisory visits are assigned and performed q 14 days.
• Maintain and receive all inter-office communications reports, telephone orders, ensure orders are activated and “copy should be kept in a CM binder”.
• Ensures that Re-certification/ Follow-Up visits are scheduled 5 days prior to next certification period. Updates physician on patient progress or any changes in patient’s condition.
• Receives patient Referrals and responsible for assigning RN to perform admission in absence of an intake nurse. Confers with third party payers as needed.
• Receives verbal reports on all new admissions, post hospitalization assessment and re-certification/ follow-up from RN’s on the day of service provided.
• Reviews all admission, re-certification/ follow-up, post-hospitalization packets prior to forwarding to Data Entry Dept.
• Performs daily patient update, verbal reports from primary nurse and review written weekly reports to assign patient for weekend visit if applicable.
• Performs as patient advocate between the field staff, physician, other disciplines, referral resources, and other involved agencies.
• Assigns Director of Clinical Services in staff performance valuation and counseling (verbal or written) as applicable.
• Assist Director of Clinical Services in staff performance valuation and counseling (verbal or written) as applicable.
• Functions in the Office as a resource person to all field staff.
• Facilitates team conference to update field staff an any changes related to patient care or problems, review agency policies and procedures and provided staff with mini In-service resources related to field staff specialty to include monthly home health aides in-services.
• Rotates on-call as assigned. Responsible for getting report from on-call RN.
• Maintains patient’s medical record, updates MAR’s Lab book, on-call book.
• Works closely with call Department or Director of Clinical Services to:

• Promote and improve patient’s quality care.
• To identify patient and field staff problems.
• To develop plan of actions and resolutions.

• Works closely with clinical Director to promote open communication, respect, professionalism, and team concepts. Reports any unusual conditions or complaints concerning patients.
• Functions as field staff nurse during extreme peaks, PRN’s and/or emergencies.
• Complies with all Federal and State regulatory and accreditation standards.
• Reviews weekly schedule, ensure that all patients are assigned. Needs to be done a week prior.
• Assigns new employees with RN field staff to ensure and perform competency skills evaluation and testing.
• Ensure that Admission Board and Discharge Board is updated by intake nurse, including hospitalized patients.
• Responsible for completing Transfer Oasis Form/Verbal order once patient is hospitalized.
• Orders all DME for patients when necessary.
• Reviews and co-signs all inter-office communications/verbal orders from field staff. Ensure that infection control report form is completed when applicable.
• Complies with all policies and procedures of the Agency.
• Represents the Agency at all times in a professional and loyal manner.
• Performs any other duties as assigned by the Administrator or Director of Clinical Services.

• Current License as a registered nurse in the State of Texas.
• 1-2 years’ experience in home health or acute care setting.
• CPR certified, ACLS/IV certification preferred.
• Able to effectively communicate with physicians, patients, or patients caregivers and other members of the team.

DEGREES OF TRAVEL:

Travel required for client visits/hourly care daily and community activities as necessary. Must have reliable transportation and agency-required liability insurance.

Regency Integrated Health Services is an Equal Opportunity Employer. Regency does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability status, national origin, veteran status or any other basis covered by appropriate law. All employment decisions are based on legitimate, non-discriminatory criteria.