Job Description

Manages and coordinates team functions and performance to ensure appropriate home care services from admission to discharge, for assigned patients. Plans and coordinates the delivery of each assigned patient’s plan of care in accordance with physician orders. Plans, renders, and evaluates hands on care provided to all assigned patients. Supervises and teaches team members, including RN’s, LPN’s, CNA’s and HMA’s in the efficient and effective delivery of quality patient care in accordance with agency policies and procedures and physician’s orders.

QUALIFICATIONS:

• Registered Professional Nurse, currently licensed in the state of Tennessee.
• Minimum two years of home health experience.
• Working knowledge of the home health care program with previous management/supervisory experienced preferred.
• Previous experience scheduling home health visits preferred.
• Must be able to provide direct patient care and take on-call.
• Must be able to travel – trips vary in length and may require overnight stay.
• Computer data entry and word processing skills desirable.

KEY RESPONSIBILITIES:

1. Assists with calls or inquiries from any referral source (hospitals, physicians, patients/family members etc.) and provides accurate and reliable information regarding the requirements for admission to home health care.
2. Assists with the solicitation of necessary patient specific information (name, address, phone, insurance, diagnosis, services required, physician etc.) at the time of referral in order to coordinate care needs and schedule a timely admission visit.
3. Obtains all patient insurance information including member ID numbers, contact numbers for insurance, and other pertinent numbers from card.
4. Conducts initial admission visits and assures that services are initiated in a timely manner as ordered by the physician. Completes supporting documentation in an accurate and timely manner, including but not limited to; referral form, consent/service agreement, OASIS, 485 initial plan of treatment, care plan/plan of care, medication profile, progress note, personal care, care plan, etc.
5. Establishes and maintains effective and efficient primary care teams and assists with scheduling in-home staff and monitors all services according to the plan of care.
6. Coordinates referrals for MSS and home health care as needed for rehab or nursing services.
7. Supervises and evaluates services provided by the RN’s, LPN’s, CNA’s and HMA’s in accordance with the plan of care, organizational policies, procedures, processes, and applicable regulations.
8. Develops and revises personal care plans as needed.
9. Performs case management visits as ordered by the MD to improve the quality of patient care.
10. Provides frequent communication to physicians, in-home staff members and others in effort to coordinate changes in patient care and to assure that appropriate follow-up and supporting documentation is done.
11. Coordinates requests/referrals for oxygen, medical equipment, pharmacy needs, community services, etc. according to patient need and physician order.
12. Assures coordination of care with physicians, labs, in-patient facilities, etc. providing relevant information in a timely manner (lab results, transfer/discharge info, status reports, etc.). Monitors patient’s inpatient status on a frequent basis and coordinates resumption of private duty services as needed.
13. Conducts resumption of care and recert visits in a timely manner as ordered by the physician. Completes supporting documentation in an accurate and timely manner.
14. Monitors all types of patient care and supporting documentation (admission, recert, resume, and routine, transfer/discharge) and assures compliance with physician orders and OASIS requirements to ensure efficient and effective patient care.
15. Assists the Billing Department with verification and timely submission of information necessary to billing process. Assists with transaction on assigned patients as needed. 
16. Generates and reviews each assigned patient certification and recertification (485).
17. Participates in team conferences for all assigned patients. Solicits input from all in-home staff involved in each patient’s care, to evaluate progress toward individual patient goals. Assists with documenting above information and providing 60 day MD summary.
18. Coordinates physicians appointments for patients. Ensures patient has scheduled face-to-face 8 weeks prior to end of patient’s reauthorization end date, and notifies DOL Coordinator of this date.
19. Assists patient in completing DOL Medical Travel Refund Request forms.
20. Completes QPDC face-to-face form to assist family, staff, or patient with getting appropriate information in the physicians note.
21. Accompanies patient to medical appointments as needed to ensure physician has complete and accurate information regarding current status of patient.
22. Is available and rotates on-call assignments when requested.
23. Understands and assures adherence to all organizational policies, procedures, and processes (administrative, personnel, clinical etc.). Seeks guidance and further clarification of organizational policies, procedures, and processes when uncertainty/confusion arises.
24. Maintains compliance with all Federal/Medicaid/Medicare/State licensure requirements and assists with preparation and participates in all such surveys. Reports to immediate supervisor any comments and/or suggestions made by a surveyor.
25. Evaluates or oversees the evaluation of all team member’s job performance, including appropriate documentation of performance evaluations and competency verification, including direct observation of patient care staff.
26. Attends in services, seminars, or other meetings as assigned by the immediate supervisor or other management.
27. Maintains confidentiality of information related to business practices, business activities and personnel.
28. Participates willingly with special projects and overtime work when requested.
29. Maintains a professional attitude when working with staff, fostering the team philosophy and team environment for all personnel.
30. Always provides proper notification and/or advance notice for absence or tardiness without abuse.
31. Does not allow personal affairs to interfere with scheduled work time.
32. Provides staff education and counseling regarding all aspects of patient care, employee performance and compliance with agency policies and procedures. Provides written documentation of employee education and counseling according to agency policies and procedures.
33. Maintains a professional appearance at all times.

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