Nurse Case Manager

Four Seasons Certified Home Health Agency; New York (NY); On-site; USD 65,000 - 95,000; Full time

Job summary

Four Seasons Certified Home Health Agency seeks an experienced clinician to coordinate patient care, develop individualized plans, and oversee clinical operations within a CHHA setting. The role emphasizes compliance with DOH/Medicare standards, OASIS familiarity, and strong communication with the interdisciplinary team.

The position requires active RN/LPN/PT or OT license, home health experience, and demonstrated leadership.

Qualifications

• Licensing required: RN or LPN or PT/OT.
• Experience in home health/CHHA setting with documentation/compliance knowledge (OASIS, 60-day episodes).
• Strong communication, organization, and leadership; EMR proficiency often required.

Responsibilities

• Patient and Care Coordination: act as advocate to help patients and families navigate health services and coordinate care with physicians, therapists, and providers.
• Enter visit frequencies for all disciplines and enter clinical notes for auth and Oasis when needed.
• Conduct visits when needed and support field clinical staff with skills, training, and education as required.
• Care Plan Development: assess patient needs and implement individualized care plans, incorporating patient/family feedback.
• Clinical Oversight: oversee coordination of cases, ensure adherence to CHHA standards, review POC and OASIS assessments.
• Documentation and Compliance: maintain accurate case records and ensure compliance with DOH and Medicare standards.
• Communication and Liaison: serve as primary contact for patients, families, and interdisciplinary care team; communicate with physicians about needs and changes.
• Monitoring and Evaluation: track progress, visit frequencies, and authorizations to support quality outcomes and timely billing.
• Additional Duties: may supervise field nurses, administer treatments, or assist with activities of daily living as needed.

Skills

RN license

LPN license

PT/OT license

Home health experience

OASIS knowledge

EMR proficiency

Leadership

Documentation skills

Tools

EMR systems

Job description

Key responsibilities

• Patient and Care Coordination:Act as a patient advocate to help them and their families navigate their health journey and access necessary services. Coordinate care with physicians, therapists, and other providers to ensure a cohesive plan.

Enter visit frequencies for all disciplines, request disciplines/services for patients as needed. Enter clinical notes for auth and Oasis when needed.

Conduct visits when needed. Support field clinical staff with skills, training and education as when needed.

• Care Plan Development:Assess patient needs to create and implement individualized care plans that meet specific health goals. This includes incorporating patient and family feedback and adjusting as needed. Enter wound or any treatment plans or orders requested by provider as needed.

• Clinical Oversight:Oversee the clinical coordination of assigned cases, often focusing on adherence to CHHA standards and regulations. This may include reviewing and approving documentation like the Plan of Care (POC) and OASIS assessments.

• Documentation and Compliance:Maintain accurate and up-to-date case records, including clinical notes and statistical documentation. Ensure all services and documentation comply with relevant standards, such as DOH and Medicare.

• Communication and Liaison:Act as a primary point of contact for patients, families, and the interdisciplinary care team. Communicate regularly with physicians regarding patient needs and changes in condition.

• Monitoring and Evaluation:Monitor patient progress, visit frequencies, and authorizations to support quality outcomes and ensure timely and accurate billing.

• Additional Duties:Some roles may involve supervising field nurses, administer certain treatments, or assist with daily living activities, depending on the specific position. Any other roles and assignments deemed necessary by the agency/DPS/Administrator.

Essential Functions

Employees must be able to move intermittently throughout the workday.

Must be able to speak the English language in an understandable manner.

Must be able to cope with the mental and emotional aspect of the position.

Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.

Must function independently, have flexibility, personal integrity and the ability to work effectively with patients, personnel and support agencies.

Must be in good general health and demonstrate emotional stability.

Must be able to relate to and work with the ill, disabled, elderly, emotionally upset and at times hostile people within the facility.

Must be able to bring ideas evidence base strategic plans to improve agency standard and growth.

Must maintain a high-level attendance, punctuality and use all communication tools available like emails, text, phone calls etc.

Must be able to use the computer, excel spread sheet, google documents, power point and available HER (Electronic Health Record)

Qualifications

• Licensing:Requires a registered nurse (RN) license or LPN (License Practical Nurse) or License PT/OT.

• Experience:Experience in a home health or CHHA setting is crucial, with specific knowledge of relevant documentation and compliance (e.g., OASIS, 60-day episodes) being highly valued.

• Skills:Strong communication, organization, and leadership skills are essential. Proficiency in EMR (Electronic Medical Record) systems is also frequently required.