Lahey Health RN Case Manager in Woburn, Massachusetts
Welcome To Beth Israel Lahey Health at Home . Our team provides high-quality home care and hospice services by partnering with physicians, hospitals and skilled nursing facilities to provide specialized care to patients in the comfort of their own home. Our team of nurses, therapists (physical, occupational, and speech), medical social workers, and home health aides work together to devise and implement a compassionate care plan that is expressly tailored for each patient.
About the Job
Position Summary: The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities in accordance with home care regulations and payer guidelines.
On Call: YesWeekends: YesShift Rotation: Yes
Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.
Essential Duties & Responsibilities including but not limited to:
Assumes responsibility to coordinate patient care for assigned caseload including but not limited to:
Appropriate delegation to LPN staff, patient condition change visits, and completion of OASIS time points. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
Completes and documents an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).Develops a patient specific plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
Initiates the plan of care and makes necessary revisions as patient status and needs change.
Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
Counsels the patient and family in meeting nursing and related needs.
Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
Provides health care instructions to the patient as appropriate per assessment and plan of care.
Instructs, supervises and evaluates home health aide care provided every two (2) weeks.
Manages episode of care in accordance with evolving nursing care needs and continued eligibility for services.
Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
Attends regular case conferences and team meetings per Clinical Manager and as needed.
Communicates with team LPN when delegating appropriate visits.
Communicates with other community providers to coordinate the care plan (i.e. Insurance case managers, high risk case managers, elder services, protective service, etc.).
Practices confidentiality principles set by the agency and federal HIPAA guidelines.
Demonstrates proficiency in OASIS completion
Clinical visit notes explain the need for the skilled nursing service in light of the patient’s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
Completes documentation in accordance with agency timeliness policies.
Maintains and updates clinical knowledge and skills based on current nursing practice.
Adheres to departmental requirements for required training.
Identifies specific learning needs & goals and collaborates with nursing leadership in developing a plan to meet them.
Participates in the weekend/holiday/on-call rotation as defined by Lahey Health at Home.
Ensures that arrangements for equipment and other necessary items and services are available.
Participates in in-service programs and supervises, teaches and precepts other nursing personnel as assigned by Clinical Manager.
Maintain strict adherence to the Continuing Care Confidentiality policy.
Incorporate Continuing Care Standards of Behavior and Guiding Principles into daily activities.
Comply with all Continuing Care Policies.
Comply with behavioral expectations of the Continuing Care Division.
Maintain courteous and effective interactions with colleagues and patients.
Demonstrate an understanding of the job description, performance expectations, and competency assessment.
Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
Participate in departmental and/or interdepartmental quality improvement activities.
Participate in and successfully completes Mandatory Education.
Perform all other duties as needed or directed to meet the needs of the department.
Registered Nurse from a Graduate of National League for Nursing accredited school of nursing
BSN, strongly preferred
Licensure, Certification & Registration:
Registered nurse with current licensure to practice professional nursing in the state of Massachusetts.
Has an active American Health Association BLS. If no American Heart Association BLS the employee must complete an annual BILHAH BLS Competency. No other forms of BLS will be accepted.
Minimum of 1-2 years nursing experience, at least one of which is in the area of public health or home care nursing with OASIS experience is preferred.
Skills, Knowledge & Abilities:
Demonstrates excellent observation and problem solving/critical thinking skills.
Well-developed verbal and written communication skills; essential computer skills to work with EMR.
Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.
Self-directed and able to work with minimal supervision.
Shows strong ability to organize and prioritize workload independently; nursing skills per competency checklist.
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