Intake and coordination of a referral from an acceptable referral source

Reviews and evaluates high risk referrals to promote more effective performance, better outcomes and proper delivery of quality home care

Initial in home evaluations and/or assessment

Establish the patient’s individualized care and medical record baseline

Collaborate with physicians, other agency staff and contract services to coordinate and implement the POC

Supervise the implementation of the POC and the quality of care delivered to the patient

Provide in home supervision of Home Health Aide Services at least every 14 days for patient receiving aide services and document the visit in the medical record

Provide supervision of LVNs assigned to patient caseload, through directing the implementation and evaluating the effectiveness of the nursing care and patient’s plan of care

Re-evaluate the patient plan of care at least every 60 days and when there is a change in the patient condition, after a hospital stay, and a time of discharge revising the Plan of Care as needed to achieve patient goals.

Documents direct patient services, coordination and collaboration with physician and other disciplines or provides in the care of the patient, ensuring the document is complete, and complies with acceptable home health standards and Agency policy.

Internal Case Manager

Review & track schedules for admissions, recertification & discharges

Help coordinate and schedule weekly work load for specific territory, utilizing clinicians to their fullest capacity

Facilitates active and effective communication with team members as demonstrated through leadership of patient case conferences, staff education or in services, and timely clinical decisions which provide guidance in the delivery of patient care.

Documentation is timely and meets professional standards of practice, establishes compliance with state regulations and Medicare conditions of participation.

Reviews caseload charts documentation at least every 60 days to ensure compliance assess patient progress and effectiveness of care delivery in meeting patient goals.

Provides patients and staff supervision 24 hours a day when assigned on-call

Available at all times during operating hours to assist clinicians as appropriate

Collaborating with leadership/management team and office staff to facilitate timely office processing of paperwork and personnel information

Actively participates in Agency quality improvement activities

Assists in the formulation, revision, implementation, and evaluation of policies and procedures, as well as strategic goals and objectives

Promote the Agency and services to the public and participate in physician and community education related to services provided by the agency

Performs other duties as assigned

Maintains responsibility to develop professional self attend seminars, and identify self -learning needs, collaborates with agency leaders in meeting learning needs

Assists DPCS in the planning, implementation, and evaluation of in-service and continuing education programs

Performs Clinician orientations

Maintain report logs

Use company EMR system (Kinnser) to perform required tasks

Assist with maintaining compliance documentation

Provide daily supervision of district nurses

Assist in completing yearly Performance Evals