Patient Care Manager
5 days ago
The Home Health Patient Care Manager is a key member of our clinical team, responsible for overseeing the delivery of high-quality patient care services. As a clinical supervisor, you will coordinate and supervise an interdisciplinary team of staff to ensure the continuity of care to home health patients assigned to the team's area.
Key Responsibilities- Referral Coordination: Receive referrals and ensure timely patient evaluation by assigning clinicians and plotting start of care (SOC) visits.
- Clinical Coordination: Coordinate determination of patient home health benefits, medical necessity, and ongoing insurance approvals.
- Patient Assessment: Ensure 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 with physician orders.
- Plan of Care Development: Oversees and assures development, implementation, and updates to the individualized patient plan of care, as appropriate.
- Communication and Documentation: Manage and document phone calls from physicians, clinicians, patients, referral sources, and communicate patient updates/new orders to clinicians.
- Quality Assurance: Reviews assessments and plans of care daily, per assigned workflow, and consults clinicians with recommendations, as appropriate.
- Care Coordination: Coordinates all aspects of care with all disciplines, physicians, durable medical equipment providers, caregivers/family members, transferring facilities, and any other applicable healthcare providers.
- Lab and Diagnostic Test Coordination: 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.
- Case Conference and Reporting: 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.
- Discharge and Transfer Coordination: Assists clinicians in coordinating the transfer and discharge of patients from agency services as indicated by the physician.
- Reporting and Documentation: Receives report from field clinicians prior to scheduled days off on patient status and ongoing needs.
- Order Processing: Processes new orders and updates the visit frequency, as appropriate, when the oncall RN takes supplemental verbal orders which alter frequency going forward.
- Order Writing and Communication: Writes and processes orders when taking verbal orders directly from the physician and communicates such to field clinicians.
- Payer Change Documentation: Assures payer change documentation is completed properly and timely, as required.
- Documentation Review: 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.
- Service Delivery Review: 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.
- Risk Management: Enters infections and incidents/occurrences into the online Risk Management Incident Reporting System, as specified by policy.
- New Hire Orientation: Assists in the orientation of new agency personnel.
- Leadership and Direction: Provides direction and leadership to clinical team members in collaboration with the clinical director.
- Patient Care: Provides direct patient care, as necessary, in accordance with scope of practice and physician orders.
- QAPI Participation: Participates in QAPI program.
- Compliance and Follow-up: Assures compliance with and ensures timely follow-up on daily clinical and coding edits.
- Best Practice Interventions: Directs clinicians in utilizing best practice interventions when finalizing Plan of Care for all patients.
- On-Call Rotation: Participates in on-call rotation.
- On-Call Follow-up: Follows-up with On-Call events daily.
- Reporting and Documentation: Receives report from weekend and after-hours clinicians admitting new patients.
- Required Training: Completes LHC required learning courses, additional assignments per Executive Director request, as well as any state specific required training per state regulation/practice act requirements.
- Episode Management: Directs team in adherence to and participates in the Episode Management process.
- Education and Experience: 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.
- State-Specific Requirements: CA: One year prior professional nursing experience, LA: At a minimum, one year of clinical experience. RN licensure must have no restrictions, AK, AL, AR, AZ, CO, CT, DE, FL, GA, ID, IL, IN, KY, MA, MI, MD, MN, MO, MS, NC, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WI, WV: No other state-specific requirements.
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