RN skilled homecare

ATC Youngstown•Vienna, OH

About The Position

The RN Clinical Manager provides clinical oversight 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. The position oversees patient assessments, OASIS documentation, individualized plans of care, CMS-485 documentation, certifications and recertifications, and quarterly clinical reports. It coordinates with physicians, patients, families, and interdisciplinary team members to support quality outcomes, continuity of care, accurate documentation, and regulatory compliance. Responsibilities include conducting and overseeing patient assessments; completing and reviewing OASIS documentation; preparing, coordinating, and maintaining home health certification and plan-of-care documents; coordinating services and monitoring patient progress; preparing quarterly clinical reports; providing skilled nursing visits and interventions as assigned; and participating in quality assurance, audits, and regulatory compliance activities. The role also requires timely communication about changes in patient condition, maintaining confidentiality, and managing assigned clinical documentation and deadlines. The position involves clinical documentation, care coordination, patient assessment, and administrative responsibilities, with travel to patient residences as required. The RN Clinical Manager may participate in clinical meetings, audits, and other agency activities.

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 patients' medical conditions, functional abilities, safety risks, medications, and ongoing skilled nursing needs.
Monitor patient progress, ensure care remains appropriate, coordinate service changes, and communicate clinical concerns promptly.
Support safe transitions of care following hospitalization, emergency department visits, or significant changes in condition.
Complete applicable OASIS assessments accurately and within required time frames; review documentation and track deadlines.
Correct documentation deficiencies and participate in OASIS audits, education, and quality improvement activities.
Prepare, review, coordinate, and maintain CMS-485 or applicable Home Health Certification and Plan of Care documentation.
Coordinate certifications, recertifications, orders, practitioner signatures, and plan-of-care revisions, and follow up on overdue or incomplete documentation.
Develop and maintain individualized plans of care based on assessments and authorized practitioner orders.
Coordinate services with nursing, therapy, social work, home health aides, and other disciplines when applicable.
Monitor implementation of ordered services and progress toward goals; follow up on missed visits, unmet goals, changes in status, and barriers to care.
Prepare and submit quarterly clinical reports, summarize patient progress and clinical indicators, identify trends and risks, and communicate findings to agency leadership.
Perform skilled nursing visits and interventions as assigned, including wound care, medication management, patient education, disease management, and other ordered treatments.
Coordinate care with physicians, authorized practitioners, hospitals, rehabilitation facilities, and other providers; follow up on outstanding orders and care 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 recommend or implement 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 and clinical meetings as required.
Maintain nursing licensure, certifications, and clinical competencies, and complete assigned documentation and administrative responsibilities by established deadlines.
Perform other related clinical duties as assigned within the RN's scope of practice.