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Registered Nurse Case Manager
Home & Health Care Management
Sacramento, USA
Full-time
Manager
Onsite
$43.00 - $53.00 / hour
Discovered 2 days ago
Role Overview
Home & Health Care Management is the oldest home health care agency in Northern California.
Our agency specializes in delivering comprehensive in-home care and case management for older adults, children, and those living with disabilities across many counties.
We use a matrix of Medi-Cal, Medicare and targeted health programs to find solutions that work for our clients.
Full Job Posting
RESPONSIBILITIES
- Able to work with clients in multiple settings and with various long-term care programs
- Participates in case conferences and educational activities as required.
- Completes all documentation for the client record on day of service.
- Utilizes the electronic health record appropriately to document information in the client record.
- Participates in mandated agency activities including staff meetings and in-service training
- Completes a nursing assessment and evaluates the client’s nursing and care needs during visits with clients in their homes, in skilled facilities, and/or via telehealth visits.
- Reports changes in client’s conditions to the client’s physician and documents these reports in the clinical record.
- Updates required documentation per program requirements.
- Completes all required documentation per agency standards.
- Participates in patient and family teaching as needed.
- Encourages a safe and sanitary environment in the client's home setting
- Reports to Adult Protective Services/Child Protective Services for any at-risk clients as required as a Mandated Reporter.
- Participates in other specific duties as assigned and defined by their supervisor.
- For Transitional Care Clients (i.e..those clients enrolled in California Community Transitions Program – CCT ):
- Assists the agency social worker with transitional care activities to allow clients to transition from skilled facilities to a home setting (house or apartment) with supportive services as available and appropriate (i.e. In Home Supportive Services and HCBA Waiver services), Residential Care Facility for the Elderly (RCFE) under the Assisted Living Waiver (ALW) Program or Congregate Living Health Facility (CLHF) under the Home and Community Based Alternatives Waiver (HCBA).
- Complete required assessments for transitional care clients using MedCompass and agency Electronic Health Records:
- Initial nursing assessment
- Collaborate with the social worker to complete the Initial Transition and Care Plan (ITCP) for CCT clients
- Complete the RN assessment section within the Final Transition and Care Plan (FTCP) for CCT clients
- Coordinate with agency social workers, clients, caregivers and facility discharge planners to ensure that clients have all necessary medical supplies, equipment and medications prior to transition from skilled facilities.
- Ensure all clients have been established with post transition providers for medical care needs
- For skilled care clients enrolled in the 811 housing programs:
- When skilled care is required, develops and implements a client-specific Plan of Treatment in conjunction with the client, physician and caregiver (as appropriate.) These Plans of Treatment are based on identified client needs and:
- Include goals with a time framework for completion.
- Are developed at the initial visit and updated as changes occur, at least every 2 months.
- Reflect coordination and cooperation with team members, physician and utilization of available community and agency resources.
- Interventions are based on nursing assessment.
- Interventions are reflective of established clinical practice.
- Ensure that there are physician orders for all skilled care that agency nursing staff performs, and that the orders are regularly and timely re-evaluated and updated.
- Administers prescribed medications and treatments and will fill medication boxes and perform medication management services when needed.
- Regularly and timely re-evaluates the Plan of Treatment. Modify or change interventions in response to patient responses, needs, requests and/or physician orders.
- Performs simple diagnostic tests (such as taking vital signs with each skilled nursing visit, performing blood glucose monitoring and taking pulse oximeter readings.)
- Complete required OASIS assessments every 2 months
- Perform supervision of home health aides every 14 days for 811 clients who also have agency Home Health Aide services.
- Collaborate with HCBA Waiver Care Management Team members to ensure all 811 client needs are met.
- For clients enrolled in the Assisted Living Waiver (ALW) Program:
- Complete an initial nursing assessment to determine tier levels for clients applying for the ALW program.
- Complete on-going nursing assessments every six months and when changes in care needs occur.
- Visit all ALW clients on their case load at least every 6 months and when changes in care needs occur.
- Collaborates with agency social workers to ensure client needs are being met.
- Develop a client-specific Plan of Care (Individual Service Plan – ISP) in conjunction with the client/legal representative, (as appropriate) program social workers, and caregivers/RCFE staff (Residential Care Facility for the Elderly) staff.
- ISPs are developed at the initial visit, and updated every six months and when changes in care needs occur. Interventions are modified/changed in response to patient responses, needs, requests
Qualifications
- Skilled in operating a computer utilizing a variety of standard software (excel, word, adobe) and Electronic Health Records.
About Home & Health Care Management
Home Care & Senior Care Services100 employeesFounded 1979
Private California home-health agency providing skilled nursing, therapy, case management, and personal care for families and disabled residents.
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