TITLE OF POSITION: CASE MANAGER TITLE OF IMMEDIATE SUPERVISOR: Clinical Director RISK OF EXPOSURE TO BLOODBORNE PATHOGENS – High DUTIES OF POSITION Maintain the quality of patient care in accordance with the Agency’s objectives and policies, through planning, coordination, implementation, and evaluation of the home services provided. Remains available during all hours that services are offered. POSITION RESPONSIBILITIES Conduct comprehensive assessments of patients’ needs and develop individualized care plans in collaboration with the healthcare team. Monitor and evaluate patient progress and adjust care plans as needed. Ensure that care plans are aligned with the patient’s goals, preferences, and medical needs. Coordinate and schedule medical appointments, therapies, and other healthcare services for the patient. Communicate effectively with patients, families, physicians, and other healthcare providers to ensure seamless care coordination. Facilitate communication between clinical staff, loved ones, and community agencies to ensure continuity of care. Supervise visiting nurses and home health aides, providing guidance and support. Provide education and support to patients and their families on managing health conditions and accessing resources. Advocate for patients’ needs and rights. Maintain accurate and thorough documentation of patient care and progress. Ensure compliance with relevant regulations and agency policies. Participate in quality improvement activities. Identify and connect patients with community resources to assist with improving compliance and treatment protocols and social issues. Assist with financial or other social issues that may provide barriers to patient compliance. Provide education/guidance to patients and families on tools to manage chronic illnesses. Develop/implement individual and web-based tools and resources to improve compliance. JOB CONDITIONS Position is stressful in terms of meeting deadlines. Primarily a desk job which involves minimal and occasional lifting of medical supplies and charts. On occasion may be required to bend, stoop, reach or move patient weighing up to 250 pounds; lift and/or carry up to 30 pounds. Travel is required to and from patient’s home. The ability to communicate well, both verbally and in writing is required. The ability to access patients’ homes which may not be routinely wheelchair accessible is required. Hearing, eyesight, and physical dexterity must be sufficient to perform a physical assessment of the patient’s condition and to perform patient care. EQUIPMENT OPERATION Use of multi-line telephone, calculator, and medical nursing equipment, i.e., glucometer, etc. COMPANY INFORMATION Has access to all patient medical records which may be discussed with Director, Clinical Director, and Quality Assurance. QUALIFICATIONS Must be a graduate of an accredited School of Nursing. Must be a Registered Nurse licensed by the state. Must have a minimum of 2 years nursing experience, one of which is in home health care. Must be familiar and have experience in OASIS. Must have a criminal background check. Must have current CPR certification. Must have current malpractice insurance. ACKNOWLEDGMENT EMPLOYEE NAME EMPLOYEE SIGNATURE DATE