Job Summary
** MUST BE FLUENT IN SPANISH SPEAKING**
The Home Health Case Manager is responsible for overseeing and coordinating patient care in the home setting to ensure safe, effective, and compassionate clinical outcomes. This role involves developing and updating individualized plans of care, reviewing comprehensive nursing assessments, and providing clinical direction and guidance to field staff to support consistent, high-quality care delivery.
The Case Manager serves as the primary point of contact for patients and their families, offering education, support, and ongoing communication to help them understand the care plan and manage health needs at home. Responsibilities also include collaborating with physicians, therapists, social workers, and other members of the interdisciplinary team to ensure continuity of care and appropriate resource utilization.
Key duties may include monitoring patient progress, identifying changes in condition, coordinating necessary services, ensuring regulatory compliance, and advocating for patient needs. The Case Manager plays a critical role in promoting patient safety, improving outcomes, and supporting families throughout the course of home health services.
Duties
- Develop and implement personalized care plans in collaboration with multidisciplinary teams, focusing on acute care, chronic disease management, behavioral health, and post-acute recovery.
- Coordinate discharge planning and transition of care from hospital to home or community-based services, ensuring continuity and quality of care.
- Facilitate intake processes for new patients by gathering comprehensive clinical information and establishing initial contact to build trust and rapport.
- Monitor patient progress through regular follow-ups, adjusting care plans as needed to address evolving health conditions or social determinants impacting health outcomes.
- Collaborate with primary care providers, specialists, social workers, and community organizations to coordinate services that support holistic patient well-being.
Qualifications
- Valid nursing license with current registration; experience in critical care settings such as ICU or Level I/II trauma centers highly preferred.
- Demonstrated expertise in hospital medicine, emergency medicine, or medical-surgical nursing with a focus on acute and post-acute care environments.
- Strong knowledge of physiology, infectious disease management, geriatrics, pediatrics (including PICU), behavioral health issues, and trauma care protocols.
- Proven experience in case management, discharge planning, utilization management, and outpatient clinic coordination.
- Familiarity with medical terminology, electronic medical records (EMR), diagnostic evaluation procedures, and HIPAA compliance standards.
- Excellent patient assessment skills combined with a proactive approach to patient service and education.
Job Types: Full-time, Part-time
Pay: $70,000.00 - $104,000.00 per year
Work Location: In person
