Rn, Care Manager (Home Health)

Essential Functions:

• Completes initial and ongoing comprehensive assessments of the patient's needs at appropriate time points as assigned. Completes the nursing assessment of assigned patients. Demonstrates ability to discuss and/or teach pertinent aspects of nursing care and patient rights and responsibilities. Identifies and reports problems, abnormal findings, or nursing diagnoses that need follow up.
• Implements plan of care in accordance with identified needs. Participates with the patient in clarifying mutually agreed upon goals and incorporates these goals into the plan of care. Provides direct and/or indirect skilled, safe, quality care. Coordinates patient care with other disciplines and integrates input from disciplines. Performs ongoing nursing assessments and changes plans of care as needed. Accurately completes and legibly documents all pertinent information in accordance with established policies and procedures by documenting patient care delivery, patient status, patient's response to treatment, and therapeutic interventions. Ensures that all documentation is completed and submitted in a timely manner. Updates nursing plans and medication profiles when changes occur.
• Counsels and educates the patient and family in meeting healthcare/nursing and related needs. Provides learning opportunities for patient and caregiver, including written material as appropriate. Initiates appropriate preventative and rehabilitative nursing procedures. Complies with all applicable legal requirements, standards, policies and procedures including, but not limited to the code of conduct, HIPAA, and documentation standards. Demonstrates professional conduct, service excellence and commitment to the mission and values of Adventist Health.
• Performs other job-related duties as assigned.
• On call duties will be assigned based on location and agency operational needs. If assigned by agency leadership, incumbent is required to perform on call duties.