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To assess, provide, coordinate and direct the Home Health patient’s care based on the individual needs of the Home Health client. The RN Case Manager is responsible for the independent management of the Home Health population using the nursing process in the residential environment. The RN Case Manager is responsible for OASIS documentation, data collection, and collaboration with other members of the Interdisciplinary Team for the client. The RN Case Manager oversees the Home Health Aide’s work and provides education to the Home Health Aide regarding infection control, standards of care, and agency policies and guidelines.

This position reports to the Oakwood Preferred Services Clinical Director.

Fully embraces a culture of hospitality and teamwork by living the Oakwood Core Values:

• Compassion: We care deeply about the people we serve and the people we work with on a daily basis. We work together to help one another.
• Faith: We have a commitment to remain true to the vision and mission of Oakwood.
• Inclusion: We include everyone. We welcome opinions and strive to consider different perspectives to create fair, welcoming, and accessible experiences for all.
• Integrity: We work to be transparent and fair. We act with honor and respect for our residents, their families, and our co-workers.
• Dedication: We care about the people we serve and work with on a daily basis. We are dedicated to providing superior service to one another and our community.

• Provide comprehensive assessment, planning, and implementation for a caseload of home health clients as the RN Case Manager. Uses health assessment data to determine nursing diagnoses and provides care requiring specialized RN skills. Synthesizes information into a comprehensive plan of care to meet the rehabilitative, therapeutic, and preventative needs of the client. Makes changes as needed when the client’s health status and needs change. Updates the Interdisciplinary Team (IDT) with changes and the client’s progression toward discharge goals.
• Provides education to the client and client supports as needed regarding the plan of care. Develops and implements feasible discharge plans before the discharge of the client. Communicates with community resources as needed to coordinate the plan of care.
• Assumes responsibility for coordination of medical orders and MD communication regarding the client’s needs and reports any changes in condition. Obtains and receives MD orders. Communicates and collaborates timely and professionally with other members of the IDT.
• Participates in on-call duties as assigned, including telephonic triage. Be available to provide after-hours services as assigned, including admissions. Ensures equipment needed in the home setting is provided and coordinates all other necessary items of durable medical equipment and disposable medical supplies.
• Participates in continuing education programs and inservices, and case conferences with other IDT members as assigned.  Assists in the supervision and evaluation of care provided by Home Health Aides as required by regulatory standards. Provides education as needed to ensure the Home Health client is receiving safe and effective care. Appropriately delegates per the Wisconsin Nurse Practice Act.
• Exhibits sound nursing judgment and decision-making skills in coordinating client care.
• Provides direction and leadership in the Home Health Department in regards to nursing practice to ensure care and quality standards are met, compliance with regulatory requirements are in place and met. Assists with staff education regarding Oakwood policies and protocols.
• Acts as a resource person on clinical challenges for all others in the Home Health Department.
• Maintains and fosters a spirit of collaboration, professional behavior, and acts as a role model for professional nurses and clinical staff.
• Fosters professional development of self and others in the department.
• Maintains consistent contact with the Home Health Office through email and voicemail within expected timelines.
• Maintains productivity according to agency standards after completing orientation. Uses technology while maintaining HIPAA and client confidentiality. Uses good judgment regarding fiscal responsibility, time management, and cost control activities.
• Demonstrates flexibility with scheduling within a face-paced and changing environment while maintaining a positive attitude.
• Maintains professional boundaries with clients, ensuring professional, client-centered care.
• Supports others in the department through group decision making, resolving conflict, and managing stress. Serves as a preceptor to new staff, as assigned.

ESSENTIAL QUALIFICATIONS

• Knowledge and ability to apply current nursing theory and practices with an emphasis on assessment skills and problem-solving techniques as they relate to resident needs.
• Motivates residents to reach their optimal level of independence.
• Learns and implements state and federal regulations that affect the care of Home Health clients.
• Carries out job responsibilities in a professional, accurate, and conscientious manner.
• Creates and maintains an atmosphere that fosters effective team relationships with other staff and with various community agencies and with the public.
• Handles confidential information according to HIPAA guidelines.
• Exercises independent judgment and make sound decisions.
• Provides on-call support as assigned, including phone triage and after-hours admissions.
• Maintains a flexible work schedule to meet the needs of clients and staff.
• Knowledgeable about CMS Home Health Conditions of Participation and Standards of Care.
• 1Works within departmental and organizational policies and procedures.
• Participates in the monitoring of nursing skills of peers and Home Health Aides using quality assurance tools as appropriate.

 EDUCATION, TRAINING AND/OR EXPERIENCE

• Graduate of an accredited school of nursing and registration or eligible for registration as an RN in the State of Wisconsin.
• Experience caring for geriatric Home Health clients is required.
• CPR certification.
• Prefer at least three to five (3-5) years of nursing experience within the Home Health environment, relevant OASIS knowledge.
• Computer skills required.