Responsible for the daily management of an assigned patient caseload, ensuring timely care and documentation to meet the patent needs/services as prescribed in the established plan of care and per MD orders Collects data pertinent to the healthcare consumer's health or the situation from patient assessments in the home setting, telephonic contacts and/or related EMR information available. Analyzes the data to determine the issues and available resources to seek effective resolution. Identifies patients at high risk for re-hospitalization, falls and/or high utilization of resources that require additional intervention and case conferencing to ensure appropriate care and frequency of services mitigates risk and ensure high quality outcomes Prioritizes multi-issue, situations appropriate to the criticality of patient health and welfare, patient/staff safety and impact to effective, timely services Identifies barriers to situation/complaint resolution (i.e. language, literacy, psychological, etc) and follows-up with the appropriate resources or leadership to address timely and effectively Develops and provides oversight of a plan of care that is effectively communicated with the parties involved and supports quality patient outcomes and patient satisfaction. Implements the identified plan, and directs the care coordination of a multidisciplinary clinical team approach, supervision of LPNs and/or HHAs involved in the care of the assigned patient caseload to promote health and safe outcomes. Performs ordered treatments, therapies, and/or procedures in accordance with State Nurse Practice Act and Home Health Conditions of Participation, JCAHO and agency policy and procedures. Evaluates progress towards attainment of patient centered goals.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
11-50 employees