RN skilled homecare

ATC Youngstown•Vienna, OH

About The Position

The RN Clinical Manager oversees and coordinates skilled home health services for assigned patients. The role ensures safe, appropriate, individualized care in accordance with practitioner orders, applicable federal and state regulations, and agency policies. Responsibilities include overseeing patient assessments and OASIS documentation; developing and managing individualized plans of care; preparing CMS-485 or applicable Home Health Certification and Plan of Care documentation; coordinating certifications and recertifications; and preparing quarterly clinical reports. The RN Clinical Manager works with patients, families, physicians, authorized practitioners, and interdisciplinary team members to support quality outcomes, continuity of care, accurate documentation, and regulatory compliance. The position includes clinical documentation, care coordination, patient assessment, administrative responsibilities, and travel to patient residences as required. The RN Clinical Manager may also participate in clinical meetings, audits, and other agency activities. The position reports to the Director of Nursing / Agency Administrator and serves an assigned service area.

Requirements

Current, unrestricted Registered Nurse license in the State of Ohio.
Graduate of an accredited nursing program.
Current CPR/BLS certification as required by agency policy.
Knowledge of OASIS, CMS-485 / Home Health Certification and Plan of Care documentation, and home health certification and recertification requirements.
Strong clinical judgment, organizational skills, attention to detail, and written and verbal communication skills.
Ability to manage multiple patient records, track deadlines, and coordinate care independently.
Proficiency with electronic medical records and clinical documentation systems.
Valid driver's license, reliable transportation, and appropriate automobile insurance when required for field visits.

Nice To Haves

Home health nursing or clinical case management experience.
Knowledge of Medicare home health regulations and applicable CMS Conditions of Participation.

Responsibilities

Perform and oversee start-of-care, resumption-of-care, recertification, transfer, and discharge assessments; evaluate patient conditions, functional abilities, safety risks, medications, and skilled nursing needs.
Monitor patient progress, coordinate changes in services when needs or conditions change, communicate clinical concerns, and support safe transitions of care.
Complete applicable OASIS assessments accurately and on time; review documentation, track deadlines, correct deficiencies, and participate in audits, education, and quality improvement.
Prepare, review, coordinate, and maintain CMS-485 or applicable Home Health Certification and Plan of Care documentation, including required practitioner signatures, orders, certifications, and recertifications.
Develop and maintain individualized plans of care based on assessments and authorized practitioner orders; coordinate services across disciplines and monitor implementation and progress toward goals.
Follow up on missed visits, unmet goals, changes in status, barriers to care, and documentation supporting medical necessity and appropriateness of services.
Prepare and submit quarterly clinical reports; summarize progress and clinical changes, review relevant safety and clinical indicators, identify trends and risks, and communicate findings and recommended follow-up to agency leadership.
Perform skilled nursing visits as assigned, including wound care, medication management, patient education, disease management, and other ordered treatments.
Coordinate care with physicians, practitioners, hospitals, rehabilitation facilities, and other providers; follow up on orders and care coordination needs.
Educate patients and caregivers about treatment plans, medications, disease management, and safety precautions.
Maintain compliance with CMS Conditions of Participation, Ohio nursing requirements, payer requirements, agency policies, and HIPAA privacy requirements.
Participate in QAPI activities, clinical record reviews, OASIS audits, and documentation compliance reviews; identify gaps and implement or recommend corrective actions.
Report incidents, suspected abuse or neglect, and patient safety concerns through appropriate channels.
Communicate professionally with patients, families, practitioners, and interdisciplinary team members; participate in case conferences, clinical meetings, and care planning activities.
Maintain required licensure, certifications, and clinical competencies; complete documentation and administrative work by established deadlines; perform other related duties within the RN's scope of practice.