RN Case Manager for Continuing Care
New Increased Salaries!
Full Time with Benefits
Rochester, New York
Newark, New York
The RN Case Manager is responsible for the delivery of comprehensive nursing care to a set of assigned patients at a specific point in time. This involves the assessment of patient and family needs and the development, implementation and evaluation of an appropriate Plan of Care, making changes in response to changing patient needs. The RN Case Manager identifies appropriate interdisciplinary services needed, coordinates those services and supervises Private Duty Nurses (PDN) as applicable.
Identifies and prioritizes health problems based on assessment
Develops or implements an interdisciplinary Plan of Care based on the needs identified during the assessment, with input from the patient (and their caregivers as applicable), in collaboration with the attending physician and other care team members
Manages and coordinates patient care, including clinically complex cases, in a manner which ensures the efficient and effective delivery of appropriate services and community supports
Exhibits proficiency and accuracy in the completion of comprehensive assessment/documentation, which may include assessments required by payer sources (e.g., Outcome and Assessment Information Set (OASIS), Hospice Item Set (HIS)).
Plans, organizes and prioritizes care needs for an assigned caseload of patients to ensure their care needs are met and services are delivered according to plan of care
Communicates all changes in patient status and/or service needs to the appropriate care team member and ensures appropriate action is taken in a timely manner
Facilitates the development and implementation of patient discharge plans as indicated
Documents all patient care and coordinating activities per agency standards
Assesses the need for additional services (aide, therapies, social work or a community service) and obtains orders and arranges care as indicated
Supervises and evaluates care provided by Licensed Practical Nurses and/or home health aides in the performance of his/her patient care duties
Works collaboratively with other care team members by communicating all changes in patient status and/or service needs to the appropriate care team member and ensures appropriate action is taken in a timely manner.
Correctly identifies patient/family risk factors and establishes goals and interventions to reduce/remove risk from the plan of care to enable patients to remain in the least restrictive care setting.
Coordinate/participate in interdisciplinary team meetings/patient care conferences.
Patient needs are prioritized; visits outside primary team assignment or geographical area may be required in order to meet patient need.
Practices according to Agency and community standards
Participates in utilization review and/or continuous quality improvement activities as requested.
Attends required staff meetings, in-services and/or supervisory conferences.
Participates in on-call schedule and weekend/holiday schedule as assigned.
About the Area:
Rochester is a city on the southern shore of Lake Ontario in western New York with a population of 208,046 residents. Rochester is the seat of Monroe County and the third most populous city in New York state, after New York City and Buffalo.
It is home to numerous cultural institutions and hosts a number of festivals every year. Popular is the Lilac Festival held for ten days every May, when more than 400 varieties of lilacs bloom, and hosts 100,000 visitors.
Lake Ontario, the Erie Canal and numerous parks provide numerous summer and winter sports such as boating, fishing kayaking, camping, tubing, skiing, skating, etc.
Niagara Falls, a national treasure, is located only 1 � away. Southeast is the Finger Lakes and wine country.
3 � hours to Adirondack Mountains
3 � hours to Toronto, Canada
Newark is a town in New York with a population of 9,068. Newark is in Wayne County. Living in Newark offers residents a suburban feel and most residents own their homes. In Newark there are a lot of parks. Many families live in Newark and residents tend to lean conservative. The public schools in Newark are above average.
It is just minutes away from NYS Thruway 90, 25 minutes north of Seneca Lake( one of the Greater Finger Lakes), 45 minutes east of Rochester, 2 hours east of Niagara Falls, 4 hours west of Albany.
Graduate of an accredited school of professional nursing and a valid NYS registered nursing license required with a minimum of one year's experience in an acute care setting required (two years preferred).
Specialized clinical experience and skills may be required for certain teams, such as infusion, oncology, pediatrics, cardiac, hospice and/or palliative care.
Must demonstrate solid interpersonal, organizational and time management skills.
Basic computer skills are necessary, including but not limited to the ability to navigate on a personal computer within a Windows-based operating environment; the ability to access and create basic e-mail messages; and the ability to open, edit and save basic electronic documents if necessary.
Must be able to document clinical notes and assessments within an electronic medical record.
With training provided, must demonstrate the ability to learn and utilized new systems, computer applications and operating environments as necessary.
A valid New York State Driver's License and the ability to pass a driver's license record background check.
Requires reliable means of transportation for use during entire shift and the ability to travel to and from required locations as needed to perform the essential responsibilities of the job.
Level II - requires similar qualifications as level I, plus:
A minimum of 2 years of home care experience.
Understands when to escalate to management.
This job is fast paced and operates in a home-like setting with direct patient contact.
This role requires regular travel (e.g. driving) to various locations and adaptability to various living conditions.
Tasks may vary based on patient need and physician directed orders.
Contact with slippery surfaces may occur, especially during icy/wintery conditions.
Contact with domestic animals may occur.
Contact with household dust, scents, and/or known job related chemicals (e.g. chemo, antiseptic agents) may occur.
Associates or better in Assoc Nursing.
Bachelors or better in Bach Nursing.
Nurse, RN or better in Nursing.
Licenses & CertificationsRequired