Develop and execute personalized care plans to improve satisfaction and outcomes for all participants.
Facilitate and complete the process of Interdisciplinary Team (IDT) meetings, Service Delivery Requests (SDR), and other meetings, including attestations as needed. Support and collaborate with the Virtual IDT as needed.
Serve as a manager on call during non-operational hours, responsible for follow-ups, documentation, and initiating grievances on participants’/caregivers’ behalf in a timely manner.
Run necessary Clinical Delivery reports.
Represent the Community Health Nurse (CHN) in IDT meetings as required.
Balance and allocate staffing and resources throughout the site, ensuring adequate team assignments and coverage.
Communicate with IDT and necessary parties to coordinate care consistent with participants’ health care needs and goals.
Collaborate with clinicians to review UAS and the UAS analyzer system to ensure accurate assessments.
Ensure incidents are investigated and addressed, completing Level 2 investigation and documentation timely according to regulations.
Ensure participant documentation is complete and accurate, including enrollment, disenrollment, electronic/paper medical records, and clinical notes.
Review participants’ charts for quality and address any deficiencies.
Provide care management services across sites, collaborating with the Transitions in Care Team and communicating with appropriate team members during care transitions.
Coordinate long-term care services in nursing homes, rehab facilities, etc., as needed.
Monitor care management activities, services, and members’ responses to interventions, implementing changes to meet needs and goals.
Ensure documentation meets standards and regulations.
Stay updated on health-related issues, procedures, clinical practices, and medications.
Recommend and contribute to service, program, policy, and procedure improvements.
Collaborate with Human Resources in conducting interviews, coaching, and disciplinary actions. Assist in staff onboarding and professional development training.
Evaluate the work performance and competency of direct reports, providing feedback, support, and completing annual performance reviews.
Ensure direct reports follow rules, regulations, and organizational policies.
Investigate and resolve employee grievances and complaints.
Serve as the Director of Patient Services (DPS) for the LHCSA, as assigned.
Perform other duties as assigned.
Experience & Skills Required
Three to five (3-5) years of administrative experience in management within a certified home health agency (CHHA), long-term home health care (LHCSA), acute care, medical-surgical, critical care, or nursing home experience.
Customer service experience is required.
Managed long-term care insurance experience beneficial.
Minimum of one (1) year of experience working with a frail or elderly population or, if less than one (1) year, appropriate training on working with a frail or elderly population upon hiring.
Supervisory experience is required.
Current active and unrestricted license and registration in New York State as a Registered Nurse required