Registered Nurse

Position Summary

The RN Case Manager is responsible for completing initial and ongoing nursing assessments, supervising Home Health Aides/PCAs, developing and updating individualized care plans, and ensuring safe, high-quality care for clients receiving non-skilled home care services.

This position focuses on assessment, evaluation, education, and regulatory compliance — not hands-on skilled nursing procedures.

Essential Functions

Initial & Ongoing Assessments

• Conduct initial in-home assessments for all new clients, including evaluation of:
  • Medical/functional history as it relates to the care plan
  • ADLs, cognition, safety, home environment
  • Risks, equipment needs, caregiver support, and overall ability to remain safely at home
• Complete 90-day, 6-month, and annual reassessments per DOH and payer requirements.
• Identify any changes in condition and coordinate follow-up with appropriate providers or care managers.
• Determine the need for Home Health Aide/PCA services and the appropriate frequency/scope of tasks.

Care Planning & Oversight

• Develop and maintain an individualized Plan of Care (POC) aligned with the patient's needs, goals, and authorized services.
• Update care plans whenever the patient’s condition or needs change.
• Educate patients and caregivers regarding safe home care practices, disease awareness, ADLs, emergency planning, and community resources.

Supervision of Home Health Aides / PCAs

• Conduct supervisory visits in the patient’s home to evaluate:
  • Quality of aide performance
  • Compliance with the care plan
  • Patient satisfaction and safety
• Provide coaching, teaching, and corrective guidance to PCAs/HHAs as needed.
• Document all supervisory contacts in accordance with DOH requirements.

Coordination & Communication

• Communicate with service coordinators, schedulers, MLTC care managers, physicians’ offices, and family members to ensure seamless care delivery.
• Report significant changes in condition promptly to appropriate parties.
• Participate in case reviews and quality improvement initiatives.

Documentation & Compliance

• Complete accurate, timely electronic documentation in accordance with DOH, Medicaid, MLTC, and agency standards.
• Maintain knowledge of New York State LHCSA regulations, infection control requirements, and payer guidelines.
• Ensure all care delivery is compliant with the care plan, authorized tasks, and scope-of-practice restrictions for LHCSAs.