RN
Supervision and coordination of clinical services
Provides and directs provisions of nursing care to patients in their homes
In compliance with applicable laws, regulations, and agency policies
Coordinates and supervises an interdisciplinary team of staff
In accordance with physician prescribed plan of care, and all applicable state and federal laws and regulations
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
Manages and documents phone calls and new orders from physicians, clinicians, patients, referral sources, and communicates patient updates/new orders to clinicians
Uses coordination notes to document, as needed and appropriate
Receives report from weekend and after-hours clinicians admitting new patients
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 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 transfer and discharge of patients from agency services as indicated by the physician
Receives report from field clinicians prior to scheduled days off on patient status and ongoing needs