The Clinical Care Manager is a registered nurse, who assesses, implements, coordinates, and monitors home care services for patients from admission to discharge. The Clinical Care Manager will develop and implement a Plan of Care based on a comprehensive initial assessment and in accordance with the physician?s Plan of Treatment. This individual will ensure effective coordination of care, continuity of services as indicated and goal achievement through discharge planning.
Essential Functions and Responsibilities:
- Assess patients, families and home environment for appropriate home care services and/or development of a Plan of Care
- Implements and monitors the continuum of care from admission to discharge
- Provides for comprehensive patient care based on nursing diagnoses and prescribed medical treatment plan
- Instructs patients and caregivers in the required provision of care
- Communicates with the health care team to coordinate the delivery of services as ordered by the physician and indicated on the Plan of Care
- Assist the team in problem solving to provide effective patient care
- Performs skilled nursing functions as needed for any assigned for any assigned patients
- Routinely provide assistance to residents which requires, lifting, pushing and balancing the equivalent of 50 pounds or greater
- Evaluates the quality and appropriateness of all health services and care delivered by team members provided to assigned patients
- Develops, implements and coordinates discharge plans and prepares discharge summaries and instructions for assigned agency patients
- Oversees the day to day operations in the Medicare Home Health Department
- Maintains and ensures current comprehensive documentation of patient assessments, clinical records, services provided, reports and other required information
- Acts as liaison to establish working relationships and facilitates communication for agencies, referral sources, health team member, administrative staff and other disciplines
- Coordinates with referral coordinator/scheduler to update patient status and changes in the Plan of Treatment and to schedule staff and services as needed
- Maintain accurate time, mileage, supply records and other agency documentation as required and turns them in on time according to agency policy
- Supervises and evaluates other health care team members assigned to respective patients (i.e. LPN, CNA/HHA). LPN once a month CNA/HHA every 14 days
- Supports and adheres to all agency policies and procedures
- Participates in staff meetings, case conferences, utilization review, in-services, workshops and required meetings
- Participates in the agency Quality Assurance Program
- Serves on agency committees for planning and problem solving
- Assist with skilled nursing assessments in Private Home Health as needed
- Weekend, holiday and on-call rotation required
Educational, Physical, and Other Requirements:
- Employee must be able to perform the essential functions of the job with or without reasonable accommodations. Physical requirements may include frequent use of hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; talk or hear. The employee may be required to lift, stand; walk; sit; climb or balance; stoop; kneel; crouch or crawl; and smell. Vision abilities may require close vision, distant vision, color vision, peripheral vision, depth perception and the ability to adjust focus.
- For the safety and security of our residents and patients, employees must be able to read, write, and verbally communicate in English, which is the most universally used language of our resident and employee population.
- Must be able to lift and/or move up to 30 pounds, and occasionally up to 50 pounds.
- Maintains current state licensure as a Registered Nurse
- Completion of a Baccalaureate in Nursing preferred
- Has a minimum of two years of medical/surgical experience as a registered nurse in an acute care setting
- A minimum of one (1) year experience as a home health field nurse is required
- Prior supervisory experience which includes team leadership and care coordination preferred
- Meet the continuing educational requirements for a Registered Nurse
- Current CPR certification
- Complete a clinical competency
- Knowledge of Medicare regulations and excellent organizational skills
- Adherence to agency safety and infection control practices
- Must be flexible and capable of maintaining regular attendance
- Hours are 8:00AM-4:30PM (Subject to change pending approval)
- Weekend, holiday and on-call rotation required
- Must meet all local health regulations and pass a pre-employment and subsequent routine physical exam, drug screen and background check
- Has a good driving record and is able to travel extensively during all seasons
- Must have dependable transportation – You will be required to use your own vehicle for work.
Customer/Guest Relations & Communications:
- Must maintain a professional, respectful, friendly demeanor with all residents, family members, guests, and staff at all times.