Job Description: Title: RN Case Manager Job Code: 14010 Division: Senior Living Status: Exempt Reports to: Director of Clinical Management Revision date: March 2019 Supervises: Nurses and Home Health Aides PURPOSE According to prescribed policies and procedures of the organization including all applicable federal, state and local regulations and under the general supervision of the Director of Clinical Management is responsible for providing nursing care services and case management to client, caregiver, and client representative by implementing nursing interventions as ordered by the physician and set forth by the plan of care. Supervises direct care staff members to deliver quality care and coordinates delivery of care services. ESSENTIAL FUNCTIONS * Assuring the development, implementation, and updates of the individualized plan of care, which would entail communication with all physicians involved in the plan of care and integration of orders from all physicians involved in the plan of care including those orders related to medications. Includes the client, caregiver, and client representative in the planning process. * Develops individualized plan of care with the involvement of the client, caregiver, and client representative and provides education, mentoring, and support throughout the plan of care. Notifies the client, caregiver, and client representative of necessary plan of care changes. * Uses health assessment data to determine problems, goals and interventions. Communicates with community health providers and facility staff to coordinate the care plan. Works with interdisciplinary team and physician/physician extender to establish, monitor and document on-going home health eligibility. * Completes an initial assessment of client, caregiver, and client representative to determine home care needs. Performs a complete physical assessment and obtains history of current and previous illness(es). * Initiates appropriate preventive and rehabilitative nursing procedures. May administer medications and treatments as prescribed by the physician/physician extender. * Communicates with the physician/physician extender regarding the client's needs and reports any changes in the client's condition; obtains/receives physician's/physician extender's orders as required. Prepares clinical notes and updates the primary physician/physician extender when necessary. * Provides direct client care as defined in the State Nurse Practice Act. * Educates and mentors the client, caregiver, and client representative in providing care related needs per plan of care. Provides support and education on end of life issues and care to clients and caregivers. * Regularly re-evaluates client nursing needs. Initiates the plan of care and makes necessary revisions as client status and needs change. * Coordinates discharge planning in conjunction with interdisciplinary members when appropriate. 2 * Attends and participates in scheduled Interdisciplinary team meetings to coordinate care plans, follow-up on changes, problem solve, etc. to ensure client's care and treatment are properly communicated, documented and in conjunction with the physician's/physician extender's orders. Plan of care is updated and appropriate to client needs. * Responsible for the instruction, evaluation, plan development, and supervision of the LPN/LVN, HH/Hospice aides per conditions of participation and as outlined by policy to include the initiation, participation, and communication of the competency evaluation. NON-ESSENTIAL FUNCTIONS * Participates in in-service programs and teaches other nursing personnel. * Participates in on-call duties as defined by the on-call policy. * Ensures that arrangements for equipment and other necessary items and services are available. EXPECTATIONS * Demonstrates and maintains a positive, professional manner, manages time efficiently and effectively, provides leadership as a role model