Community Care Nurse – Hct – RN

Community Care Nurse – Hct – RN

Requirements

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Critical thinking skills required.
• Ability to work autonomously is required.
• Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.
• Ability to plan, implement and evaluate individual patient care plans.
• Ability to work as oversight for License Practical Nurse (LPN) for initial assessments, plan of care and supervisory visits including proper discharge of a patient from case management.
• Knowledge of nursing and case management theory and practice.
• Knowledge of patient care charts and patient histories.
• Knowledge of clinical and social services documentation procedures and standards.
• Knowledge of community health services and social services support agencies and networks.
• Organizing and coordinating skills.
• Ability to communicate technical information to non-technical personnel.
• Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
• Spoken and written fluency in English. Bilingual a plus.
• This job requires use and exercise of independent judgment.

Responsibilities

• Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital.
• Provides home visits to perform initial assessment of patient and the development of care plan for the Licensed Practical Nurse (LPN) to use as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
• Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
• Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.
• Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
• Completes individual plan of cares with patients, family/care giver and care team members.
• Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
• Assesses the environment of care, e.g., safety and security.
• Assesses the caregiver capacity and willingness to provide care.
• Assesses patient and caregiver educational needs.
• Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
• Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches’ patients in using natural supports and mainstream community resources to address supportive needs.
• Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
• Establishes a supportive and motivational relationship with patients that support patient self-management.
• Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
• Home visit under the direction of the patient’s primary care physician to meet urgent patient needed.
• Performs other duties as assigned and modified at manager’s discretion.

Preferred Qualifications

• Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in home in a related clinical field preferred.
• A minimum of 1 year of case management experience in community case management experience highly desired.
• Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.