Patient Care Manager and RN/Registered Nurse Hybrid

The Home Health Patient Care Manager and RN Hybrid is responsible for the supervision and coordination of clinical services and provides and directs provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies.
Coordinates and supervises an interdisciplinary team of staff to assure the continuity of high quality care to home health patients assigned to the team's area in accordance with physician prescribed plan of care, and all applicable state and federal laws and regulations.

• Receives referrals and ensures appropriate clinician and/or therapist(s) assignments for timely patient evaluation by signing off after authorization and plotting start of care (SOC) visits.
• Coordinates determination of patient home health benefits, medical necessity, and ongoing insurance approvals.
• Ensures patient needs are continually assessed and care rendered is individualized to patient needs, appropriate and reasonable, meets home health eligibility criteria, and is in accordance to physician orders.
• Manages and documents phone calls and new orders from physicians, clinicians, patients, referral sources, and communicates patient updates/new orders to clinicians.
  Uses coordination notes to document, as needed and appropriate.
  Receives report from weekend and after-hours clinicians admitting new patients.
• Coordinates all aspects of care with all disciplines, physicians, durable medical equipment providers, caregivers/family members, transferring facilities, and any other applicable healthcare providers.
  Follows-up on lab and other clinical diagnostic test, physician contact, and significant changes in the patient condition to ensure adequate physician notification, follow-up, and needed plan of care modifications and communicates such to clinicians.
• Schedules, prepares for, facilitates, and documents case conference/SOC reports and facilitates effective exchange of information across disciplines especially with adverse findings, changes in patient condition, daily and urgent updates, as necessary.
• Assists clinicians in coordinating the transfer and discharge of patients from agency services as indicated by the physician.
• Receives report from field clinicians prior to scheduled days off on patient status and ongoing needs.
• Assures payer change documentation is completed properly and timely, as required.
• Reviews clinician visit notes weekly to ensure timely, complete, appropriate, and accurate submission of all documentation by field staff.
  Takes necessary action to correct adverse findings and communicates trending to clinical director.
• Reviews, evaluates, and supervises service delivery to ensure appropriateness of care and utilization of services, equipment, and supplies through activities such as random patient visits, medical record reviews and case conferences.
• Enters infections and incidents/occurrences into the online Risk Management Incident Reporting System, as specified by policy.
• Assists in the orientation of new agency personnel and provides direction and leadership to clinical team members in collaboration with the clinical director.
• Provides high quality clinical services within the scope of practice and within infection control standards, in accordance with the plan of care, and in coordination with other members of the health care team.
  Consistently meets expected productivity at 50% of full time RN level as defined in the Visit Productivity Point Policy.
• Accurately and timely completes the comprehensive assessments (OASIS) including medication reconciliation.
  Makes the initial and/or comprehensive nursing evaluation visit, ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source, accurately determines primary focus of care, develops the plan of care within State specific guidelines with the physician, and submits accurate documentation.
• Directly and/or indirectly supervises care provided by the home health aides and licensed practical vocational nurses, provides instruction as appropriate, and assigns tasks according to State and federal regulations.
  Also provides required supervisory visits.
• Initiates, develops, implements, and makes necessary revisions to the plan of care in collaboration with the physician and other health care professionals involved in care.
• Communicates relevant information timely and effectively with appropriate agency staff including but not limited to:
  any patient care issues or needs, visit assignments, dates of scheduled visits, and schedule changes to scheduler, orders and OASIS data sets, coding requests, schedule home visits, to coordinate care with other clinicians, Communicates timely and effectively with physicians, patients, and family members to ensure quality care and service excellence.
• Follows-up with On-call events daily.
• Participates in On-call rotation.
  
• All other duties as assigned.
  

• Current RN licensure in state of practice
• Current CPR certification required
• Current Driver's License, vehicle insurance, and access to a dependable vehicle or public transportation

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