Field RN Case Manager - Care at Home

Field RN Case Manager - Care at HomeThe Registered Nurse plans, organizes, and directs home care services and is experienced in nursing with emphasis on community health education/experience. The professional nurse builds from the sources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. Current Florida Nursing License required Must have at least one (1) years experience in home health care or the acute care settingNursing staff education experience preferred.

Demonstrated effective organization and time management skills. Demonstrated ability/possession of interpersonal skills. Demonstrated excellent knowledge of current nursing and patient care practices and the ability to learn and teach new concepts.

Demonstrated ability to apply nursing theories and trends appropriately in the clinical setting. Admits patient to service per established procedure:Completes an initial assessment of patient and family to determine home care needs. Evaluates home environment to assure services can be safely provided in the homeObtains a complete physical assessment and history of current and previous illness.

Advises patient of rights on initial visit. Includes the patient and the family in the planning process. Uses health assessment data to determine nursing diagnosisDevelops a plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions.

Initiates the plan of care and makes necessary revisions as patient status and needs change. Furnishes services requiring substantial and specialized nursing skill through the initiation of appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.

Completes start-of-care and comprehensive assessments, and updates, within established time frames. Maintains the electronic clinical record for each patient receiving nursing care. Regularly re-evaluates patient's nursing needs.

Revises plan of care based on changes in physician orders. Provides health care instructions to the patient as appropriate per assessment and plan of care. Counsels the patient and family in meeting nursing and related needs.

Completes start-of-care and comprehensive assessments, and updates, (including a drug regimen review) within established time frames. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. Acts as Case Manager in all cases involving nursing or both nursing and therapy care when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.

Documents case conferences to demonstrate that effective interchange, reporting and coordination of patient care took place. Instructs, supervises and evaluates home health aide care provided every two (2) weeks. Maintains accepted standards of productivity.