Nurse Case Manager

Clinical Assessment & Care Planning

• Completes and documents initial assessments, reassessments, and significant change in condition assessments for new starts, restarts, and ongoing cases in the EMR per company standards and applicable state requirements.
• Develops, implements, and updates individualized plans of care based on assessed needs, client/family goals, and provider direction.
• Identifies clinical risks and changing conditions; initiates timely interventions and escalates to the appropriate provider, family, internal leadership, or emergency services when indicated.
• Collaborates with clients/families to set realistic goals and ensure day-to-day care supports those goals.
• Maintains monitoring of clinical outcomes and identifies opportunities for quality improvement and enhanced care delivery.

Field Clinical Oversight & Care Professional Support

• Provides field-based clinical oversight to ensure care is delivered safely and consistent with the plan of care and scope of practice.
• Educates and coaches Care Professionals on client-specific care needs, safety, infection prevention, documentation expectations, and red flags for escalation.
• Communicates care plan updates and client status changes to Care Coordinators and assigned care professionals to support safe staffing and continuity of care.
• Identifies caregiver training needs and collaborates with internal leadership to coordinate competency development and education.
• Provides clinical feedback regarding Care Professional performance, including adherence to care plans, documentation accuracy, and clinical skills.
• Escalates concerns through appropriate internal channels.

Coordination, Orders, and Stakeholder Communication

• Communicates clinically relevant changes to practitioners and other stakeholders; requests/obtains practitioner orders as applicable to the service model and state requirements.
• Prepares accurate reports/updates for external stakeholders (e.g., care managers, payers, facilities, referral sources) as required for the case.
• Serves as a clinical liaison to strengthen relationships with clients, families, referral partners, and community providers.

Documentation & Compliance

• Maintains timely and accurate documentation in the EMR according to company policy, payer expectations (when applicable), and state/federal regulatory requirements.
• Documents field visits, assessments, care plan updates, caregiver instructions, and follow-up actions.
• Ensures required client documentation is available and maintained in both electronic and in-home formats when applicable.
• Protects confidentiality and complies with HIPAA and company privacy/security standards.

On-Call / Coverage (As Assigned)

• Participates in an on-call rotation as assigned, responding to clinical questions, urgent client issues, and changes in condition consistent with the 24/7 nature of home care.
• Maintains expected service and documentation standards during on-call coverage.