Skilled Nursing Visits – RN Case Manager

This Clinician provides and documents skilled nursing care to pediatric and adult patients, reporting to the SNV Clinical Supervisor. This role ensures compliance with MGA, State, and accrediting agency policies, reimbursement guidelines, and HIPAA. The Clinician manages patient care plans per physician orders and assists with planning, organizing, and managing patient care under the direction of the Director of Clinical Services (DOCS) or SNV Clinical Supervisor.

Responsibilities/Duties:

• Manage weekly caseload set by the SNV Clinical Supervisor.
  • Provide skilled nursing care per physician orders, continuously assess and update the care plan.
  • Establish patient baseline and needs; communicate with families to schedule visits.
  • Stay informed about state and federal regulations impacting home care.
• Effectively manage the EMR:
  • Timely submission of assessments, visit notes, orders, and other client documents.
  • Confirm schedules to ensure visit frequency accuracy.
  • Respond to communications (email, Teams, EMR) promptly.
• Identify and address changes in patient status:
  • Notify Clinical Supervisor and communicate with physicians for sudden or significant changes.
  • Document care and demonstrate critical thinking in resolving issues.
  • Administer treatments/medications per orders and provide patient/caregiver education.
  • Collaborate with interdisciplinary teams for optimal patient outcomes.
• Assist with additional duties as assigned by the SNV Clinical Supervisor, including:
  • Coordinating patient and personnel assignments, referrals, and continuous assessment of individualized care plans.
  • Filling in for SV nurses when needed, including starting care for patients, which may later be passed to per-visit nurses.
  • Participating in relevant clinical and departmental meetings.
  • Ensuring compliance and contributing to quality improvement and utilization review efforts.
  • Train newly hired clinicians in field visits, EMR documentation, and skills competencies.
  • Assist with staff supervisory visits and complete annual clinical and operational competencies on time.
• Participate in limited and as needed “After Hours Standby RN” schedule as assigned, assisting with admissions or visits after hours.
• Report any suspected abuse, neglect, or exploitation as required by law.
• Maintain competencies in all Skilled Visit (SV) clinical skills, ensuring compliance with regulatory requirements and patient safety standards.
• Participate in Care Coordination Meetings and provide clinical leadership in problem-solving.