Clinical Field Staff Supervisor (R.N. Care Manager) - Mays Home Health

REPORTS TO: DIRECTOR OF NURSES (DON)

QUALIFICATIONS EDUCATION/TRAINING/EXPERIENCE

1. Must be currently licensed as an RN through the Board of Nursing in the state of practice.
2. Must have at least an Associate’s Degree in Nursing.
3. Prefer one year clinical experience in the health care industry, and one year experience in home health. Must understand the issues related to the delivery of home health services and be able to problem solve effectively and possess knowledge of the Medicare guidelines governing home health agencies or have experience/abilities that indicate with training they would excel.
4. Prefer supervisory experience

CHARACTERISTICS

1. Must be organized, detail oriented and possess effective communication skills, both orally and in writing. The ability to communicate with a diversity of individuals is required.
2. Must have good clinical judgment and observation skills
3. Must have a positive attitude, is self-directed and has the ability to work with little supervision
4. Must be willing to comply with accepted professional standards and principles.
5. Must be flexible and cooperative in fulfilling role obligation. 6. Must have satisfactory references from previous (or current) employers, nursing school, and/or professional peers.

MINIMUM REQUIREMENTS

1. Must possess a valid state driver’s license and adhere to all state laws while driving
2. Must possess automobile liability insurance
3. Must have dependable transportation kept in good working condition
4. Must be able to drive an automobile in various types of weather/road conditions
5. Must possess intermediate computer skills

SUMMARY OF JOB RESPONSIBILITIES

The Clinical Field Staff Supervisor (CS) is responsible for the overall coordination of home health services provided to Medicare and non-Medicare patients. The CS is responsible for the provision of quality services according to acceptable clinical and agency standards of practice and continually monitors the services provided. The CS is a resource person that gains extensive knowledge of the regulatory and practice guidelines governing home health agencies-who ensures compliance with agency policies, State and Federal laws and regulations. The CS is the liaison between the community, referral sources, physicians, patients, caregivers, agency staff, and contract disciplines.

RESPONSIBILITIES AND DUTIES

1. Provides a positive work environment by consistently modeling in a positive way, the agency philosophy, mission, values, and standards of care, and providing a professional role model for other staff. Ensures field staff are educated on process and regulatory changes.
2. Adheres to HIPAA regulations and follows agency protocol maintaining confidentiality and does not improperly disclose of patient information.
3. Complies with all agency policies and procedures.
4. Is diligent in activities that ensure advanced proficiency in Homecare Homebase (HCHB) Electronic Health Record (EHR). Actively seeks out training and continuing education in agency processes including participation in offered classroom training and e-learning courses. Communicates as appropriate with staff, physicians, referral sources, community, patients, potential patients, caregivers, and others involved in care.
5. Receives referrals with enthusiasm from physicians and staff and may participate in entering referral into the Electronic Health Record (EHR). Clearly identifying the referral source.
6. Provides supportive activities to obtain Delayed Physician Certification for Home Health Services (also referred to as Face-to-Face (F2F)) if the Certification was not received upon referral. Activities may include but, are not limited to assisting with completing the Delayed F2F form for DON approval, coordinating with physician to set up appointment, coordinating with patient/caregiver for reminder and to ensure they have transportation to the appointment, and tracking receipt of F2F.
7. Ensure patients on services meet criteria established by their payer source such as medical necessity and homebound status and ensure documentation clearly indicates the criteria are met.
8. Ensure assessing clinicians and ancillary staff provides exceptional patient care by utilizing all elements of the nursing process and/or agency standards of care. Ensure the level of care and services provided coincide with the patients’ level of acuity and meet their needs.
9. Ensure assessing clinicians and ancillary staff is providing care within their scope of practice and submits quality documentation authenticating appropriate assessment and intervention provided to the patient.
10. Completes Client Related Task of Review Evaluation Documentation which presents in workflow once the assessing clinician has completed the evaluation to ensure quality care, quality documentation, criteria met for patient to qualify for services and plan of care established to meet the needs of the patient. A. Review all required items such as Unlisted Item Report (to coordinate adding unlisted allergies, meds, and/or supplies), Visit Note (for information regarding patient status), Medication Profile (to review contraindications), Calendar (to ensure proper disciplines, frequencies, and buddy codes), Problem Statements/Care Plans (to ensure proper 485/goals and pathways), OASIS Report (for HIPPS,HHRG and OASIS info), Coordination Notes (for idea of patient status), Aide Care Plan (for aide services), Supply Requisition, Initial Order (for review), Authorization Information Report (for non-Medicare patients), Case Mix Details and Insight Report (for insight into clinical, functional, and service areas), Medicare Utilization Summary (Episode Analysis Tool to manage financial viability, revenues, costs, and visit details), Therapy Report (to determine likelihood of need for therapy), HHCAHPS Survey Data (Home health survey data), etc. B. Review non-required items as indicated such as OASIS, Vital Sign Parameters (to ensure patient specific parameters are set), Previous Orders, Pharmacy Info, 485 order, and Claim Codes (to ensure accurate billing codes). C. Coordinate with assessing clinician to assist in establishing short and long term therapeutic goals and setting priorities. Receive authorization from the assessing clinician to make necessary edits to reflect an accurate assessment and to provide patient with appropriate pathways, interventions and services. Coordinate with assessing clinician and physician to establish a plan of care and initiate services specific to the patient’s needs.
11. Reviews various types of coordination notes which communicate pertinent patient information or data related to patient care and provision of services. Provide additional coordination with physician, disciplines, and patient/caregiver as necessary.
12. Reviews coordination notes that are automatically generated when medication issues are recognized and communicates drug interactions, duplications, and contraindications to the physician within establish Medicare timelines. Implements instruction given by physician regarding the medication issue(s), communicates physician’s response to the patient/caregiver, and follows-up to ensure compliance. Reviews/Edits/Approves 485 ensuring diagnoses/coding are accurate and calendar is complete with disciplines/frequency/buddy codes, collaborating with the assessing RN to receive authorization to edit as necessary. Holding 485 so that workflow will go to Patient Services Coordinator (PSC) to schedule and so that additional clinical review can be performed.
13. Reviews additional assessment comparison tools such as SHP (Strategic Health Care Programs) to measure outcomes, to ensure OASIS/coding accuracy, and to ensure services provided to patients is concurrent with National and State Standards.
14. Reviews/Edits/Approves held 485 for thorough review of all data fields making spelling and grammar corrections, ensuring orders concur with assessment and OASIS documentation, and goals/interventions are specific to patient needs. Once complete work flow will then go to the Coding Specialist for review.
15. Reviews list of recommendations made by the Coding Specialist and collaborates with assessing clinician to review/implement/reject recommendations related to coding, OASIS accuracy, and documentation. Obtains authorization from the assessing clinician prior to editing and completes appropriate coordination note to indicate to the Coding Specialist recommendations that were accepted or declined.
16. Collaborates with other disciplines such as therapy when patient has medical necessity and meets criteria for such services. Integrates their assessment into the EHR following the workflow of Reviewing Add-on documentation, Review/Edit/Approve Add-on Order, and any other patient related task including updating the calendar to include the visits. Continues to monitor to ensure these disciplines are following the established plan of care, is compliant with re-assessments within the timelines established by Medicare, providing excellent patient care, providing quality documentation, and meeting the needs of the patient. Reviews discipline only discharges to ensure frequency and goals have been met.
17. Maintains communication regarding patient care with the physician and other disciplines involved in the care. Receive calls from field staff and physicians regarding patient care issues/orders. Enters orders as appropriate and updates the medication profile and schedule. Enters information regarding all communication into the Coordination Notes section of the EHR. Updates the plan of care as necessary and notifies physician and staff as appropriate to ensure proper coordination of care.
18. Reviews/Edits/Approves new orders as they appear on the Action Screen. Approves or declines as appropriate. Follows-up with licensed clinician to receive authorization as necessary should orders need to be edited. Updates the client’s medication profile and schedules as applicable; via the order. Ensures all orders that address frequency have appropriate calendar modification completed. Reviews and re-approves declined orders.
19. Ensures supervisory visits of home health aides are scheduled and performed in person, by required discipline, within timelines in compliance with federal regulations.
20. Enters transfers to inpatient facility as soon as being made aware of the transfer and generates hospital hold orders. Follows-up with hospitalized patients frequently and ensures the hospital discharge planner knows the patient is on our home health services. Enters order for ROC visit and reviews/edits/approves the ROC order. Reviews ROC evaluation documentation collaborating with the assessing clinician to receive authorization to make edits as necessary. Ensures calendar is updated with necessary visits and buddy codes new/changed medications have been added to the profile.
21. Enters Discharges for patients that are still in inpatient facilities at the end of episode.
22. Review/Edit/approve follow-up orders and held follow-up orders and Reviews follow-up Evaluation Documentation for patients who have been recerted (similar to the SOC workflow). Collaborates with assessing clinician to receive authorization to make edits as necessary. Ensures calendar includes proper disciplines, frequency, and buddy codes. Completes other tasks as directed within workflow.
23. Collaborates with Triage On-Call nurse making them aware of potential after hour activity that may occur with high risk patients. Reviews On-Call Coordination Notes every am and receives report from the Triage On-Call nurse as necessary to be informed of after hours activity that occurred with patients. Ensure continuity of care and follow-up with patient as indicated, ensure orders were written as necessary to accommodate patient needs, ensure meds/calendar was updated as indicated, and ensure documentation is thorough.
24. Reviews and processes all wound score deviations taking appropriate action such as coordinating with physician, communicating with staff, patient, and/or caregiver, updating supply needs, and writing orders.
25. Reviews and processes Vital Sign Alert Reports to determine if any patient vital signs fell outside patient specific parameters as established at admission/recert or per subsequent physician order. Reviews EHR to see if physician contact was made by the field nurse and ensure action is documented. Ensures proper care is provided to the patient by following-up on physician notifications and collaborating with them to update the plan of care to include additional visits, update teaching plans, etc to meet the needs of the patient and then communicate with patients as warranted.
26. Constantly reviews workflow screen. Diligently and accurately completes all tasks included within client related tasks, coordination notes, and administrative tasks in a timely manner.
27. Assesses, evaluates and regularly re-evaluates the needs of patients. Monitors visit frequency, documentation, costs and patient outcomes. Adjusts plan as needed for safety and improvement of patient’s condition, ensuring the stabilization and/or improvement of the patient’s outcomes. Makes onsite visits with patients or other members of the healthcare team when the complexity of the care warrants. Complex issues would include but, are not limited to difficult wounds, unacceptable home environment, functional decline, significant change in mental status, etc.
28. Reviews all clinicians’ documentation to ensure excellent care, quality documentation, improving outcomes, and medical necessity to ensure the provision of services and documentation required for financial reimbursement for care completed on a timely basis and in compliance with state and federal regulations.
29. 29. Understands priority is patient care. Must be willing to assist in whatever ways necessary to meet this goal including providing the hands on patient visits—from personal care to skilled care as needed.
30. Ensures customer service is being provided to all patients, physicians and other affiliates. Enters complaints into the database as received by patient, caregiver, physician, etc. so that workflow presents to the DON who will investigate the complaint. Assist the DON with investigation and resolution of complaints as needed.
31. Enters Medication errors into the database upon occurrence and collaborate with DON to receive direction on further action.
32. Enters occurrences into the database upon notification and collaborates with DON to receive direction on further action.
33. Ensures field staff follows protocols and take necessary action to prevent the spread of infectious diseases. Processes infection control report and reviews for indication of spread of infection. Collaborates with DON to receive direction when indication of spread is indicated.
34. Participates enthusiastically as a team member that actively supports the short and long-term growth objectives of the office.
35. Participates in Visit Nurse On-call rotation and assumes on-call duties as assigned. Must be available 24 hours per day when scheduled to be on-call. Must be reachable at all times and comply with the On-Call Process.
36. Participates as directed by the DON on the peer review committee presenting patient case studies for review. Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities and will be directed by their Director of Nurses (DON) or Area Clinical Supervisor as the need arises.

WORKING CONDITIONS

1. General office.
2. Work is moderate with a combination of sitting, standing, and walking
3. 3Community and client home environment.
4. Potential exposure to blood and/or body fluids and infectious disease during the performance of job duties.
5. Potential exposure to extreme temperature and humidity when traveling and while in client homes.
6. Potential exposure to dust, gas, fumes, and odors during traveling.
7. This position has been designated as clinical management (see Infection/Exposure Control Plan). Employees performing clinical management duties may be involved in potential exposure to blood borne pathogens and other potentially infectious materials. All clinical management employees will be offered Hepatitis B vaccination at no expense to the employee.

PHYSICAL REQUIREMENTS

1. Visual and manual dexterity is required
2. Good physical stamina and mental health is required. Has completed the agency pre-employment health clearance.
3. Ability to perform tasks involving physical activity, which may include heavy lifting and extensive bending and standing.
4. Ability to deal effectively with stress.

CONTINUING EDUCATION REQUIREMENTS

The Clinical Field Staff Supervisor (CS) must meet the required continuing education hours for state certification as a nurse in Texas as applicable. Agency personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, agency personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All agency personnel must attend mandatory educational programs.