Home Health Patient Care Manager RN
1 week ago
LHC Group is seeking a highly skilled and compassionate Registered Nurse (RN) to join our team as a Home Health Patient Care Manager. As a key member of our interdisciplinary team, you will be responsible for providing high-quality patient care and coordinating services to ensure the best possible outcomes for our patients.
Responsibilities:- Coordinate and supervise an interdisciplinary team of staff to ensure the continuity of high-quality care to home health patients.
- Receive referrals and ensure appropriate clinician and/or therapist assignments for timely patient evaluation.
- Coordinate determination of patient home health benefits, medical necessity, and ongoing insurance approvals.
- 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 to physician orders.
- Oversee and assure development, implementation, and updates to the individualized patient plan of care, as appropriate.
- 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 daily, per assigned workflow, and consult clinicians with recommendations, as appropriate.
- 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 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.
- 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, as necessary.
- Assist clinicians in coordinating the transfer and discharge of patients from agency services as indicated by the physician.
- Receive report from field clinicians prior to scheduled days off on patient status and ongoing needs.
- Process new orders and updates the visit frequency, as appropriate, when the oncall RN takes supplemental verbal orders which alter frequency going forward.
- Write and process orders when taking verbal orders directly from the physician and communicates such to field clinicians.
- Assure payer change documentation is completed properly and timely, as required.
- Review 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.
- Provides direction and leadership to clinical team members in collaboration with the clinical director.
- Provides direct patient care, as necessary, in accordance to scope of practice and physician orders.
- Participates in QAPI program.
- Assures compliance with and ensures timely follow up on daily clinical and coding edits.
- Directs clinicians in utilizing best practice interventions when finalizing Plan of Care for all patients.
- Participates in on-call rotation.
- Follows-up with On-Call events daily.
- Receives report from weekend and after-hours clinicians admitting new patients.
- 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.
- Directs team in adherence to and participates in the Episode Management process.
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