Patient Care Manager

The Home Health Patient Care Manager 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.   

Provides clinical services within the scope of practice, as defined by the state laws governing the practice of nursing, in accordance with the plan of care, and in coordination with other members of the health care team. 

Receives referrals, ensures appropriate clinician assignments, evaluate patient orders, and plot start of care 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 with physician orders. 

Reviews assessments and plans of care daily, per assigned workflow, and consults clinicians with recommendations, as appropriate. 

• 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.
• Oversees and assures development, implementation, and updates to the individualized patient plan of care, as appropriate.
• Manages and documents phone calls from physicians, clinicians, patients, referral sources, and communicates patient updates/new orders to clinicians. Uses coordination notes to document, as needed and appropriate.
• Reviews assessments and plans of care daily, per assigned workflow, and consults clinicians with recommendations, as appropriate.
• 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.
• Processes new orders and updates the visit frequency, as appropriate, when the oncall RN takes supplemental verbal orders which alter frequency going forward.
• Writes and processes orders when taking verbal orders directly from the physician and communicates such to field clinicians.
• 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.
• 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.
• All other duties as assigned.

Education & 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

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