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Home Health RN Case Manager - F/T - Join Our Dynamic Optimal Team!

Department: Nursing
Location: Bakersfield, CA


The Case Manager (RN) using discretion and independent judgment coordinates the delivery of quality patient care by assuring that the nursing care plan is followed. This position requires skill in planning and organizing nursing care; applying advanced nursing clinical skills, maintaining records and charts, preparing written reports, teaching other nursing-related skills and maintaining effective working relationships with others. The Case Manager is a licensed Registered Nurse who provides direct and indirect patient care services in the home on an intermittent basis under the order of a physician and in accord with the policies and procedures of Optimal Home Health. Has the ability to demonstrate the knowledge and skills necessary to provide care, based on physical, psychosocial, educational, safety and related criteria, appropriate to the age of the patients served in his/her assigned service area. The skills and knowledge needed to provide such care may be gained through education, training or experience.


  1. *Must possess a current California State Registered Nurse license.
  2. *One (1) year acute care experience is required, and preferably six (6) months community health or home health care with the past five (5) years. Other home health experience may be considered on an individual basis, i.e., Certified Home Health Aide, Licensed Vocational Nurse, etc.
  3. Must have a valid driverís license in the State of California and an insured automobile in good operating condition.
  4. *Current CPR certification.
  5. *Compliance with principles of Standard Precautions/occupational exposure to blood-borne pathogens and/or toxic substances.
  6. *Use of proper body mechanics to prevent injury to self and/or patients. Lifting, bending, transferring of patient, equipment, etc. will be required.
  7. *Must be able to manage multiple priorities and possess effective time management and organizational skills.
  8. *Ability to effectively present information in one-on-one and small group situations to patients, family members, physicians and team members.
  9. *Must be able to effectively problem solve client/patient issues.
  10. *Must participate in maintaining a safe work place.


  1. *Responsible for coordinating and participating in the assessment, evaluation and planning of patient care, and revising as necessary to include completion of all 485ís with each start-of-care and subsequent recertification. These documents must be accurate and submitted timely as per agency policy.
  2. *Responsible for evaluating and re-evaluating patient status regularly.
  3. *Initiate, develop and implement the patientís plan of care, including preventative and rehabilitative services and making appropriate referrals.
  4. *Address all nursing diagnoses identified in the Plan of Care.
  5. *Provide education to patient/family/caregiver concerning knowledge deficits or needs regarding the patientís condition.
  6. *Responsible for coordinating the total plan of care and conference with other disciplines involved in the case.
  7. *Report signs and symptoms signaling a change in patient condition to the patientís physician.
  8. *Responsible for making a supervisory visit every two weeks when a home health aide is involved in the patientís care. If the case is a therapy-only case, the supervisory visit can be done by the registered therapist.
  9. *Supervises the LPN/LVN in the administration of nursing care to the clients.
  10. *Reassess the patient within 24 hours following a change in patient condition. Reassess the patient within 48 hours following discharge from a 24 hour or longer hospital stay.
  11. *Responsible for making all reasonable efforts to be the first discipline to visit the patient following hospitalization. The Case Manager will then re-assign disciplines as needed.
  12. *Responsible for continuous reviewing all aspects of every patient on his/her caseload. This will include appropriate utilization of services ensuring continued skilled need, monitoring of homebound status and review of documentation in medical records.
  13. *Participates in mandatory case conferences facilitated by his/her supervisor.
  14. *Responsible for maintaining agency defined productivity.
  15. Participates in in-services/education programs.
  16. *Provides own car for field work and keeps accurate visit records, mileage and maintains time card/sheet on daily basis.
  17. *Within six (6) months demonstrates knowledge of Medicare regulations and third-party reimbursements, accrediting body regulations, local, State and Federal regulations that affect their practice.
  18. *Within six (6) months demonstrates knowledge of community resources.
  19. Responsible for covering nursing on-call either on weekends or evenings as needed.
  20. Works a minimum of one weekend a month and one of the three major holidays (Thanksgiving, Christmas, New Years).

* Essential Functions


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