Patient Care Manager RN

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The Home Health Patient Care Manager is responsible for the overall supervision and coordination of clinical services. 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
• 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