Home Health Patient Care Manager RN

6 days ago

St Louis, Missouri, United States Brookdale Home Health St. Louis Full time
About the Role

We are seeking a highly skilled and experienced Patient Care Manager RN to join our team at Brookdale Home Health St. Louis. As a key member of our clinical leadership team, you will be responsible for overseeing the delivery of high-quality patient care in the home setting.

Key Responsibilities
  • Supervise and Coordinate Clinical Services: Ensure the continuity of high-quality care to home health patients assigned to your team's area, in accordance with physician-prescribed plans of care and applicable laws and regulations.
  • Lead Interdisciplinary Team: Coordinate and supervise an interdisciplinary team of staff to deliver comprehensive care to patients in their homes.
  • Ensure Patient Needs are Met: Continuously assess patient needs and ensure care rendered is individualized, appropriate, and reasonable, meeting home health eligibility criteria and physician orders.
  • Develop and Implement Patient Plans of Care: Oversee the development, implementation, and updates to individualized patient plans of care, as necessary.
  • Communicate with Physicians and Clinicians: Manage and document phone calls from physicians, clinicians, patients, referral sources, and communicate patient updates/new orders to clinicians.
  • Review Assessments and Plans of Care: Review assessments and plans of care daily, per assigned workflow, and consult with clinicians with recommendations, as needed.
  • Coordinate Care with Healthcare Providers: Coordinate all aspects of care with all disciplines, physicians, durable medical equipment providers, caregivers/family members, transferring facilities, and any other applicable healthcare providers.
  • Follow-up on Lab and Clinical Diagnostic Tests: Follow-up on lab and other clinical diagnostic tests, physician contact, and significant changes in patient condition to ensure adequate physician notification, follow-up, and needed plan of care modifications.
  • Facilitate Effective Exchange of Information: Schedule, prepare for, facilitate, and document case conference/SOC reports and facilitate effective exchange of information across disciplines, especially with adverse findings, changes in patient condition, daily and urgent updates.
  • Assist with Patient Transfers and Discharges: Assist clinicians in coordinating the transfer and discharge of patients from agency services as indicated by the physician.
  • Process New Orders and Updates: Process new orders and updates the visit frequency, as necessary, when the on-call RN takes supplemental verbal orders which alter frequency going forward.
  • Assure Payer Change Documentation: Assure payer change documentation is completed properly and timely, as required.
  • Review Clinician Visit Notes: Review clinician visit notes weekly to ensure timely, complete, appropriate, and accurate submission of all documentation by field staff.
  • Supervise Service Delivery: Review, evaluate, and supervise 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.
  • Enter Infections and Incidents/Occurrences: Enter infections and incidents/occurrences into the online Risk Management Incident Reporting System, as specified by policy.
  • Provide Direction and Leadership: Provide direction and leadership to clinical team members in collaboration with the clinical director.
  • Participate in QAPI Program: Participate in the Quality Assurance and Performance Improvement (QAPI) program.
  • Ensure Compliance with Clinical and Coding Edits: Assure compliance with and ensure timely follow-up on daily clinical and coding edits.
  • Direct Clinicians in Best Practice Interventions: Direct clinicians in utilizing best practice interventions when finalizing Plan of Care for all patients.
  • Participate in On-Call Rotation: Participate in on-call rotation.
  • Follow-up with On-Call Events: Follow-up with On-Call events daily.
  • Receive Report from Weekend and After-Hours Clinicians: Receive report from weekend and after-hours clinicians admitting new patients.
  • Complete Required Learning Courses: Complete LHC required learning courses, additional assignments per Executive Director request, as well as any state-specific required training per state regulation/practice act requirements.
  • Direct Team in Adherence to Episode Management Process: Direct team in adherence to and participates in the Episode Management process.

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