The Home Health Case Manager is a RN possessing special knowledge of care practices and regulations required for provision of comprehensive care to patients in their homes, managing the care plan for a group of assigned patients.
This is a field based position and functions autonomously and in collaboration with all members of the healthcare team to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for ESRD and CKD patients.
The RN Case Manager consults as needed with the physician and the office giving details about patient care. Performing accurate OASIS collection, ensuring the medication profile remains current, ensuring lab values have been reported to the physician timely, attending weekly case conference and monthly case manager meetings are key responsibilities of this role.
As a Senior Field-Based Case Manager, you'll wear many hats, and work in a variety of environments. Sometimes, you'll interact with members leaving the hospital - possibly with new medications or diagnoses.
Provides ongoing evaluation of the patient and family / caregiver response to care, and recommends alteration of the plan when necessary. Ensure continual assessment of patient and family needs from admission to Bridges home based care throughout the course of care.
Engaging members / families in their homes or in a facility to coordinate services, community resources and treatment needs. Delivering a holistic approach to coordinated care based on the members needs using a person centered approach.
Work in collaborative practice with the physician and other members of the health care team to meet patient - specific and age - related patient needs, linking cost resource management and quality to patient care.