SUMMARY: Under the supervision of the Clinical Manager, the AHD Wound Care Center Case Manager (RN) is responsible for providing comprehensive case management services to clients identified with complex wound conditions and assist them with social challenges that are at risk for health status decline. The AHD Wound Care Center Case Manager (RN) performs the primary function of an RN in assessing, planning, implementing, and evaluating the care of patients in the Wound Healing Center. This role is responsible for meeting the established Standards of Nursing Practice in the management of all assigned patients. Assists physicians with the development and implementation of wound treatment plans and participates in performance improvement review activities. Acts within the guidelines of federal and state laws, JCAHO Standards and professional and ethical practice.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Support and adhere to AHD and Hospital policy and procedures. Initiate a nursing assessment of patient's condition upon admission. Assess, stage, measure wounds, and photograph wounds. Interpret reports and communicating findings with the assigned physician. Recognize and assess initial alterations in the patient's body systems and verbalize this to other members of the health care team.

2. Organize assessment data for accuracy, completeness and confidentiality. Record assessment data in an orderly fashion and communicate, revise and verbalize pertinent information to other health care team members. Complete in an accurate manner all admission nursing chart forms.

3. Assist physician with wound therapy. Implement wound care and HBO protocols when clinically indicated.

4. Collaborate with physician to develop a plan of care based on assessment data. Identify patient care situations that require intervention, implement nursing actions and evaluate responses. Identify patient/family education and discharge needs and implement a teaching plan of care. Identify the patient's present and potential problems from the assessment. Determine patient's health status and incorporate into the plan of care.

5. Continued assessment of compliance to the clinical pathway and be instrumental in bringing to the attention of the physician or health care team missing components. Document a plan of care accurately for all assigned patients.

6. Function as a case manager for a cohort for would care patients. Identify home health care needs, evaluate support systems, and identify patient teaching needs from admission to discharge. Coordinate office visits, pre-procedure work-ups, and patient education with the multidisciplinary team. Coordinate the use of clinic staff, exam room space, and supplies. Foster continuity of care between the wound care center and care taker (home, hospital, home health, etc).

7. Individualize care according to age specific population. In collaboration with the physician and other health care members (rehab, nutrition, diabetic education, home health, DME, nursing homes and other ancillary services), revise the plan of care and continuously reassess and evaluate until desired outcome is obtained. Complete the 4 week reviews in a timely manner and ensure all recommendations to the plan are activated in the physician orders. Participate in quality improvement/staff meetings.

8. Develop and implement a teaching plan. Prioritize problems according to impact on health status. Formulate desired outcomes specific to patient's problems and wound care center protocols.

9. Assess whether the plan of care is effective with the physician and is instrumental in initiating changes as necessary. Ensure desired outcomes that are mutually agreed upon by the patient, family (when appropriate) and the nurse. Formulate desired outcomes that are specific and measurable within a certain time frame and consistent with other health provider's expectations. Evaluate achievement or lack of achievement of desired outcomes. Participate in implementing planned changes and activities to improve care.

10. Accurately complete the superbill and ensure that all orders and charges are initiated accurately.

11. Prepare for clinic to enable accurate and complete updates to the physician. Triage telephone calls and assist with scheduling. Safely operate all clinical equipment in the clinic. Monitor condition of equipment and report malfunctions to Clinical Manager. Maintain appropriate infection control procedures. Maintain skills and knowledge through training and continuing education.

12. Hold self and staff accountable for the delivery of quality nursing care. Promote harmonious relationships and favorable attitudes among the team members. Assist others within the clinic. Maintain an open, professional communication line with patients, physicians, and staff. Adhere to time and attendance policies.

MINIMUM QUALIFICATIONS: Education: Registered Nurse, graduate from an approved School of Nursing. Master's Degree preferred. Minimum Experience: 6 months wound care experience required. Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California. BLS- Basic Life Support Certification- issued by AHA- American Heart Association. Preferred Licenses/Certification: Certification in Wound Care (WOCN, CWS, or WCC).