Day (United States of America) Field RN Case Manager - Care at Home 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 sources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. • Current Florida Nursing License required • Must have at least one (1) years experience in home health care or the acute care setting • Nursing staff education experience preferred. • Demonstrated effective organization and time management skills. • Demonstrated ability/possession of interpersonal skills. • Demonstrated excellent knowledge of current nursing and patient care practices and the ability to learn and teach new concepts. • Demonstrated ability to apply nursing theories and trends appropriately in the clinical setting. Admits patient to service per established procedure: • Completes an initial assessment of patient and family to determine home care needs. • Evaluates home environment to assure services can be safely provided in the home • Obtains a complete physical assessment and history of current and previous illness. • Advises patient of rights on initial visit. • Includes the patient and the family in the planning process. • Uses health assessment data to determine nursing diagnosis • Develops a plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. • Initiates the plan of care and makes necessary revisions as patient status and needs change. • Furnishes services requiring substantial and specialized nursing skill through the initiation of appropriate preventive and rehabilitative nursing procedures. • Administers medications and treatments as prescribed by the physician. • Completes start-of-care and comprehensive assessments, and updates, within established time frames. • Maintains the electronic clinical record for each patient receiving nursing care. • Regularly re-evaluates patient's nursing needs. • Revises plan of care based on changes in physician orders. • Provides health care instructions to the patient as appropriate per assessment and plan of care. • Counsels the patient and family in meeting nursing and related needs. • Completes start-of-care and comprehensive assessments, and updates, (including a drug regimen review) within established time frames. • Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. • Acts as Case Manager in all cases involving nursing or both nursing and therapy care when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload. • Documents case conferences to demonstrate that effective interchange, reporting and coordination of patient care took place. • Instructs, supervises and evaluates home health aide care provided every two (2) weeks. • Maintains accepted standards of productivity.