Patient Care Manager​/RN

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Home Healthcare, a part of LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here.

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General Role

Description:

The Home Health Patient Care Manager/RN 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. Coordinates and supervises an interdisciplinary team of staff to assure the continuity of

high quality

care to home health patients assigned to the team's area in accordance with physician prescribed plan of care, and all applicable state and federal laws and regulations.

Primary Responsibilities:

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.

Manages and documents phone calls and new orders from physicians, clinicians, patients, referral sources, and communicates patient updates/new orders to clinicians.

Uses coordination notes to document, as needed and appropriate.

Receives

report

from weekend and after-hours clinicians admitting new patients.

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 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.

Follows-up with On-Call events daily

Assures payer change documentation is completed properly and

timely, and

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 and provides direction and leadership to clinical team members in collaboration with the clinical director.

Provides high quality clinical services within the scope of practice and within infection control standards, in accordance with the plan of care, and in coordination with other members of the health care team.

Consistently meets expected productivity at 50% of

full

time RN level as defined in the Visit Productivity Point Policy.

Accurately and timely completes the comprehensive assessments (OASIS) including medication reconciliation. Makes the initial and/or comprehensive nursing evaluation visit, ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source, accurately determines primary focus of care, develops the plan of care within State specific guidelines with the physician, and submits accurate documentation.

Directly and/or indirectly supervises care provided by the home health aides and licensed practical vocational nurses, provides instruction as appropriate, and assigns tasks according to State and federal regulations.

Provides

required

supervisory visits.

Initiates, develops, implements, and makes necessary revisions to the plan of care in collaboration with the physician and other health care professionals involved in care.

Communicates relevant information timely and effectively with appropriate agency staff including but not…