Job: Registered Nurse Case Manager - Santa Fe, New Mexico

A Registered Nurse Case Manager is responsible for planning coordinating, providing and documenting care for an assigned caseload of patients from day of admission through day of discharge. Utilizing physician
* s orders and professional skills, develops and implements a Home Health care plan that meets the patient
* s specific need and is in compliance with Federal and State regulations, reimbursement guidelines as well as agency policies and procedures. Additionally is a Registered Nurse who is responsible for providing and documenting skilled care, as assigned, for patients with a variety of complex needs, including, but not limited to; skilled observation and assessment, management and evaluation of a care plan, teaching and training, administration of medications, wound care, catheter care, nasopharyngeal and tracheostomy suctioning, ostomy care and teaching, and rehabilitative nursing. All skilled services must be provided under a physician
* s order and the Registered Nurse; must have demonstrated professional competency prior to performing any skills. All care must be provided in compliance with Federal and State regulations, reimbursement guidelines, and agency policies and procedures.

Performs admission assessment within 48 hours of referral or as directed by referral source including completion of OASIS.
2. Develops a written plan of care in collaboration with physician for each patient based on assessment.
3. Initiates a plan of care determined by the assessment process with goals established for the appropriate outcomes and in compliance with physician orders.
4. Provides periodic reassessment of the patients nursing needs.
5. Provides those services requiring substantial and specialized nursing skills.
6. Initiates appropriate preventive and rehabilitative nursing procedures.
7. Prepares and submits timely and accurate OASIS, clinical and progress notes, payroll and other agency documentation per agency policy.
8. Coordinates and oversees all services related to care and treatment of patient.
9. Informs the physician and other personnel of changes in the patients condition and needs.
10. Counsels and educates the patient and family regarding disease process, self care techniques in health prevention, disease prevention strategies and health promotion.
11. Participates in in-service programs, team meetings, and case conference.
12. Maintains productivity standards per policy.
13. Supervises and teaches other nursing personnel as directed by Clinical Manager.
14. Refers patients to other services as appropriate.
15. Promotes patient and family independence.
16. Participates in on-call as scheduled.
17. Evaluates the ongoing effectiveness and outcomes of care.
18. Provides supervision of LPNs and Paraprofessionals providing services to the patient.
19. Plans for the patients discharge from home healthcare service.
20. Notifies the physician and Clinical Manager of SOC report/status within 24 hours of admission.
21. Ability to accurately assess and document client condition, teaching, skilled care provided every visit.

Requirements:

Education:Graduate of a school of professional nursing approved by the National League for Nursing.
Experience as a RN commensurate with one of the following:
One year acute care experience in the last two years.
* One year Medicare Home Care experience in the last two years.
* One-year community health or public health experience in the last two years.
* One-year outpatient facility experience in the last two years.
One-year long-term care experience in the last two years.