RN skilled homecare

RN Clinical Manager Skilled Home Health

The RN Clinical Manager is responsible for clinical oversight and coordination of skilled home health services for assigned patients. This position ensures that patients receive safe, appropriate, individualized care in accordance with physician or other authorized practitioner orders, applicable federal and state regulations, and agency policies.

The RN Clinical Manager oversees patient assessments, OASIS documentation, development and management of individualized plans of care, CMS-485 documentation, certifications and recertifications, and quarterly clinical reports. This position coordinates with physicians, patients, families, and interdisciplinary team members to promote quality outcomes, continuity of care, accurate documentation, and regulatory compliance.

Essential Duties and Responsibilities

1. Clinical Management and Patient Assessments

• Perform and oversee applicable patient assessments, including start-of-care, resumption-of-care, recertification, transfer, and discharge assessments.
• Evaluate patient medical conditions, functional abilities, safety risks, medications, and ongoing skilled nursing needs.
• Monitor patient progress and ensure care remains appropriate to the patient's condition and established goals.
• Coordinate changes in services when patient needs or medical conditions change.
• Identify clinical concerns and communicate them promptly to the appropriate healthcare provider and agency leadership.
• Support safe transitions of care following hospitalization, emergency department visits, or other significant changes in condition.

2. OASIS Assessments and Documentation

• Complete applicable OASIS assessments accurately and within required time frames.
• Ensure OASIS documentation reflects the patient's actual clinical status and is consistent with supporting clinical records.
• Review assessments for completeness, accuracy, and compliance with current CMS guidance.
• Track required assessment completion and submission deadlines.
• Correct identified documentation deficiencies and participate in OASIS audits, education, and quality improvement activities.

3. CMS-485 / Home Health Certification and Plan of Care

• Prepare, review, coordinate, and maintain the CMS-485 or applicable Home Health Certification and Plan of Care documentation.
• Ensure the plan of care accurately reflects patient-specific diagnoses, medications, treatments, services, visit frequencies, duration, goals, and other required elements.
• Coordinate certification and recertification documentation with the appropriate physician or authorized practitioner.
• Obtain and track required signatures and returned orders to support timely completion of the clinical record.
• Monitor certification periods and follow up on outstanding certifications, recertifications, and orders.
• Update or coordinate revisions to the plan of care when patient conditions, treatment needs, or ordered services change.
• Ensure changes to the plan of care are communicated to the appropriate care team members and documented.
• Maintain organized records of plans of care, certifications, recertifications, and signed orders.
• Identify overdue or incomplete documentation and promptly escalate unresolved issues.

4. Plan of Care Management

• Develop and maintain individualized plans of care based on patient 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 established goals.
• Follow up on missed visits, unmet goals, changes in patient status, and other barriers to care.
• Ensure documentation supports the medical necessity and appropriateness of ordered services.

5. Quarterly Clinical Reports

• Prepare and submit quarterly clinical reports for assigned patients or caseloads according to agency policy and applicable contractual or payer requirements.
• Summarize patient progress, changes in condition, skilled interventions, and progress toward care-plan goals.
• Review relevant clinical indicators, including hospitalizations, emergency department visits, falls, medication-related concerns, wound status, and other patient safety issues.
• Identify trends, clinical risks, and opportunities to improve patient outcomes.
• Communicate significant findings and recommended follow-up actions to agency leadership.
• Maintain complete and timely records of reports and related follow-up.

6. Skilled Nursing and Care Coordination

• Perform skilled nursing visits as assigned and within the RN's scope of practice.
• Provide skilled nursing interventions, 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, changes in condition, and care coordination needs.
• Educate patients and caregivers regarding treatment plans, medications, disease management, and safety precautions.

7. Quality Assurance and Regulatory Compliance

• Maintain compliance with applicable CMS Conditions of Participation, Ohio nursing requirements, payer requirements, and agency policies.
• Participate in quality assurance and performance improvement (QAPI) activities.
• Conduct or participate in clinical record reviews, OASIS audits, and documentation compliance reviews as assigned.
• Identify documentation gaps and implement or recommend corrective actions.
• Monitor clinical documentation for accuracy, completeness, and timeliness.
• Maintain patient confidentiality in accordance with HIPAA and applicable privacy requirements.
• Report incidents, suspected abuse or neglect, and patient safety concerns through appropriate channels.

8. Communication and Professional Responsibilities

• Maintain professional communication with patients, families, physicians, practitioners, and interdisciplinary team members.
• Participate in case conferences, clinical meetings, and care planning activities as required.
• Maintain required nursing licensure, certifications, and clinical competencies.
• Complete assigned documentation and administrative responsibilities within established deadlines.
• Perform other related clinical duties as assigned within the RN's scope of practice.

Qualifications

• 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.
• Home health nursing or clinical case management experience preferred.
• Knowledge of OASIS, CMS-485 / Home Health Certification and Plan of Care documentation, and home health certification and recertification requirements.
• Knowledge of Medicare home health regulations and applicable CMS Conditions of Participation preferred.
• 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.

Performance Standards and Accountability

The RN Clinical Manager is accountable for:

• Accurate and timely completion of applicable OASIS assessments.
• Preparation, review, tracking, and maintenance of CMS-485 / Home Health Certification and Plan of Care documentation.
• Timely follow-up on required practitioner signatures, orders, certifications, and recertifications.
• Accurate and current individualized plans of care.
• Completion of quarterly clinical reports by established agency deadlines.
• Timely communication of changes in patient condition and other significant clinical concerns.
• Organized management of assigned clinical responsibilities and outstanding documentation.
• Compliance with agency policies, applicable regulations, and quality improvement requirements.

Working Conditions

This 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.