Under the general supervision of the Director of Nursing Services, Registered Staff Nurse Case Manager provides professional nursing services to individuals and their families in their homes, in the agency office, and at other community sites. She/he cooperates with other health and social service agencies in promoting and maintaining the health of all community residents.
Job Responsibilities and Functions
The function of the nurse case manager is to manage a caseload of patients and/or families, serving as primary nurse and coordinating their health care plans. Responsibilities include interdisciplinary patient care coordination and supervision to ensure compliance with practice and regulatory guidelines; clinical supervision and development of direct nursing, social services, and home health aide staff to promote quality care and positive outcomes and documentation review to validate care delivery and compliance.
Operational and Care Coordination Functions
- Manage a caseload of patients and/or families, serving as primary nurse and coordinating their health care plans.
- Complete and process all paperwork according to agency expectations: plan of care, OASIS, and documentation of all visits.
- Facilitates accurate, timely and efficient documentation of reimbursed services
- Assess patient/family health status and develop a plan of care to meet each patient’s needs in collaboration with other health team members and the patient/family.
- Assessments and care plan development are specific to the patient’s age and specialty nursing needs, as indicated.
- Observe, record and report to the patient’s physician, with accuracy and timeliness, the patient’s progress, response to nursing intervention, and any changes in condition, including reaction to drug and other therapies.
- Establish realistic measurable goals when implementing care plans, involve the patient/family in all aspects of care and adjust plans according to the patient’s progress
- Respect the rights of the patient to informed decisions regarding care, particularly when differences exist between the patient’s needs, applicable laws and regulation, and/or the agency’s capability or mission.
- Consider social and environmental factors affecting the patient’s condition and incorporate these factors into the care plan. Ensure social, cultural, religious, and ethical issues/conflicts are resolved involving the patient, family, physician, and appropriate NVNA staff.
- Demonstrate sound nursing judgment in rendering skilled nursing care to all patients, whether in their homes, the agency office or other community sites.
- Registered Nurse, with a current license to practice in Massachusetts in good standing
- Baccalaureate Degree or a Master’s Degree in Nursing from an accredited school of nursing preferred
- Minimum of three years clinical experience with one-two years in a Medicare certified home health agency
- Current knowledge of Medicare Conditions of Participation and Massachusetts nursing practice guidelines
Leadership and Practice Responsibilities
- Utilizes the American Nurse Association’s Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements, as the foundation of agency nursing practice
- Promotes agency mission, values and philosophy to ensure quality patient care
- Demonstrate a positive and cooperative attitude in all interactions, contribute to team spirit and development.
- Participate in public relations activities sponsored by the agency; represent the agency on community committees and in professional organizations as requested and as time permits.
Performance Improvement Responsibilities and Functions
- Promotes customer service by responding to and resolving difficult and sensitive patient and staff inquiries and complaints
- Continuously monitors and evaluates the efficiency and efficacy of service delivery methods and processes, assesses and monitors workload, support systems and identifies opportunities for improvement
Personal and Professional Development
- Maintains professional practice standards and complies with all Massachusetts’ Board of Nursing licensing requirements
- Pursues opportunities to promote personal, professional and nursing leader development and educational advancement
- Maintains proficiencies necessary to perform role and functions
- Ability to Adapt-demonstrate flexibility by displaying ability to adapt to change; understand and promote the value of different ideas and opinions; ability to adjust plans and objectives when given new direction or priorities; handle stressful situations effectively.
- Act as Team Player-foster respect and trust with the team; communicate openly and honestly; listen attentively and respond to internal and external “customers” in a timely manner; address conflict or unpleasant situations when it occurs; actively participate in team meetings, committees and taskforces; demonstrate a willingness to pitch in and help peers and co-workers when called upon.
- Potential exposure to a variety of diseases which may be communicable in nature
- Latex exposure can be expected as some environments are not latex free
- May travel from office to meetings, patient homes and other facilities for extended periods of time and in a variety of weather conditions
- Some non-standard work hours and all-call are required
- Additional certifications may be required, including basic life support depending on work area
Minimum Physical Requirements
- Standing, sitting walking, bending, squatting, repetitive movements, driving
- Weight lifting up to 50 pounds and weight transferring up to 150 pounds
About Natick Visiting Nurse Association:
Looking to join one of the most technologically-innovative, well-respected home health agencies in Massachusetts? Natick VNA, has earned the coveted double 5-star designation from CMS and is a nationally-recognized, Home Care Elite Agency – honored for its excellent clinical outcomes and exceptional patient satisfaction – is looking for some talented, home care-passionate clinicians to become members of its Home Care Team. As one of only two Massachusetts agencies accredited by the Community Health Accreditation Program (CHAP), Natick VNA is committed to its patients, its staff, and the community.