Role and Responsibilities The LHCSA RN Case Manager is responsible for managing each clients care as efficiently and cost-effectively as possible, to achieve positive patient outcomes regardless of payer. The RN Case Manager is responsible for the overall plan of care and the outcome of that care, including care delivered by other staff (LPN, HHA, PCA) who must be directed and supervised by the LHCSA RN. Essential Functions Overall responsibilities include: providing and coordinating quality patient care while maintaining a case load/productivity as assigned by direct supervisor. Accurate and timely documentation supporting care provided and/or needs of the client. + Conduct admission assessments and determine if a safe plan of care can be administered on the admission visit. Case manage primarily aide-related services according to regulatory guidelines. Includes but is not limited to obtaining a medical history, particularly as it relates to the present condition, from the client and/or family member(s) when applicable. + Conduct a physical examination of the client including vital signs, physical assessment, mental status, appetite and type of diet, assessment of activity of daily living, and advanced directives. + Evaluate the clients support system(s) and needs as it relates to health teaching. + Medication reconciliation. + Case management. + Case conference according to established schedule. + Evaluate the clients physical environment to determine needs as it relates to durable medical equipment and physical support required to assist in activities of daily living. + Evaluate the need for home health aide/personal care assistant support including time of day, frequency of visits and length of time required to complete the plan of care. + Meeting regulatory requirements and having a comprehensive understanding of various insurances. + Provide annual administrative evaluations for assigned aides. + Practice according to best practice standards and regulatory nursing standards. + Maintain 12 CEUs as it relates to licensed home care & nursing services. + Identify potential Skilled nursing services, treatments and preventive procedures and make referrals to the CHHA and/or Health Home. + Observe signs and symptoms as it relates to the holistic plan of care and report change in condition to the physician per regulatory guidelines. + Maintain relationships and clear lines of communication with MLTC case managers and other members of the care team. + Teach, supervise and counsel the client, family and caregivers regarding the plan of care. Oversee the care given by home health aides and personal care aides. + Communicate effectively with aides, provide mentoring & positive feedback through phone conversations, and visits + Oversee clinical skills of assigned aides, provide training. + Communicate with aide preceptor regarding skills, possible support needed in field. + Mentor new hires with consistent oversight. + Supervise and evaluate the care given to the client. + Document according to standards of nursing practice. + Demonstrate competencies as they relate to information/technology. + Document those services rendered to the client, changes noted in the clients condition and/or family and home situation; revise the plan of care as needed to ensure holistic needs are met. + Contact the primary physician and/or notify the clinical supervisor per regulatory guidelines. + Establish and maintain relationships with community partners. + Prepare and present informational educational sessions to the community. + Other duties as assigned. This job description reflects managements assignment of essential functions; and nothing in this herein restricts managements right to assign or reassign duties and responsibilities to this job at any time.