RN Team Leader

JOB DESCRIPTION RN TEAM LEADER Manages and coordinates team functions and performance to ensure appropriate home care services from admission to discharge, for assigned patients. Plans and coordinates the delivery of each assigned patient's plan of care in accordance with physician orders. Plans, renders, and evaluates hands on care provided to each assigned patient. Supervises and teaches team members, including RN's, LPN's and HHA's in the efficient and effective delivery of quality patient care in accordance with agency policies and procedures and physician's orders. Performs HCHB functions, in order to improve the clinical, operational and financial success of the agency. QUALIFICATIONS: Registered Professional Nurse, currently licensed in the state of Tennessee. Minimum two years of home health experience. Working knowledge of the home health care program with previous management/supervisory experienced preferred. Previous experience scheduling home health visits preferred. Must be able to provide direct patient care and take on-call. Must be able to travel - trips vary in length and may require overnight stay. Computer data entry and word processing skills desirable. KEY RESPONSIBILITIES: Assists with calls or inquiries from any referral source (hospitals, physicians, patients/family members etc.) and provides accurate and reliable information regarding the requirements for admission to home health care. Assists with the solicitation of necessary patient specific information (name, address, phone, insurance, diagnosis, services required, physician etc.) at the time of referral in order to coordinate care needs and schedule a timely admission visit. Obtains required billing information and coordinates prior approval to obtain pre-certification authorization including any co-payments or deductibles the patient is responsible for on admission, when indicated. Conducts initial admission visits and assures that services are initiated in a timely manner as ordered by the physician. Completes supporting documentation in an accurate and timely manner, including but not limited to; referral form, consent/service agreement, OASIS, 485 initial plan of treatment, care plan/plan of care, medication profile, progress note, personal care, care plan, etc. Establishes and maintains effective and efficient primary care teams and assigns each patient to a visiting nurse and monitors subsequent visits according to the plan of care. Coordinates referrals for Special Disciplines (PT, OT, ST, MSS) and assures timely initial evaluation visits and subsequent visits according to the plan of care. Assigns, develops, supervises, and evaluates nursing services provided by the RN's and LPN's, in accordance with the plan of care, organizational policies, procedures, processes, and applicable regulations. Assigns, develops, supervises, and evaluates personal care services provided by the home health aide in accordance with organizational policies, procedures, processes and Medicare/State regulations. Develops and revises, when indicated, the personal care, care plan for each patient receiving home health aide visits. Provides frequent communication to physicians, visiting staff members and others in efforts to coordinate changes in patient care and assures appropriate follow-up and supporting documentation is done. Coordinates requests/referrals for oxygen, medical equipment, pharmacy needs, community services, etc. according to patient need and physician order. Assures coordination of care with physicians, labs, in-patient facilities, etc. providing relevant information in a timely manner ( lab results, transfer/discharge info, status reports, etc.). Monitors patient's inpatient status on a frequent basis and coordinates home health resume care orders/visits as indicated. Conducts resumption of care and recert visits in a timely manner as ordered by the physician. Coordinates subsequent visits with the primary nurse and special discipline staff. Completes supporting documentation in an accurate and timely manner. Completes and posts weekly schedules for all members providing care to the assigned patients. This includes visit schedules for the RN, LPN's, HHA's, and special discipline staff providing care to each assigned patient for regular weekday and weekend visits. Monitors all types of patient visits and supporting documentation (admission, recert, resume, prn, and routine, transfer/discharge) and assures compliance with physician orders and OASIS requirements to ensure efficient and effective patient care. Assists the Billing Department with verification and timely submission of information necessary to bill. Assists with transaction on assigned patients. Generates and reviews each assigned patient certification and recertification (485) and monitors timely receipt of signed/dated physicians orders. Notifies Director of Patient Care of outstanding orders on a frequent basis. Schedules, announces, and conducts team conferences for all patients assigned to the team. Solicits input from all visiting staff involved in each patient's care, to evaluate progress toward individual patient goals. Assists with documenting above information and providing 60 day MD summary. Assists in making prn and routine patient visits in the absence of the visiting staff. Is available and rotates on-call assignments when requested. Understands and assures adherence to all organizational policies, procedures, and processes (administrative, personnel, clinical etc.). Seeks guidance and further clarification of organizational policies, procedures, and processes when uncertainty/confusion arises. Maintains compliance with all Federal/Medicare/State licensure requirements and assists with preparation and participates in all such surveys. Reports to immediate supervisor any comments and/or suggestions made by a surveyor. Evaluates or oversees the evaluation of all team member's job performance, including appropriate documentation of performance evaluations and competency verification, including direct observation of patient care staff providing care. Responsible for HCHB responsibilities: (9/15/2008) Receive calls from field staff and physicians regarding patient care issues/orders. Enter orders as appropriate and update the medication profile and schedule. Enter information regarding all telephone calls into the Coordination Notes section of the computer software. Notify staff, as appropriate to ensure proper coordination of care. Receive referrals from physicians and staff and enter referral form in Homecare Homebase. Clearly identify who called in the referral. Assign Licensed Professional to conduct the evaluation visit, as the task appears on the action screen. Participate in weekly Case Conference and address recert/discharge decisions based on Case Conference findings. Enter Case Conference notes in Coordination Notes within 24 hours of the Case Conference meeting. Contact physicians to obtain orders for continued services provision or add-on services. Review orders, as they appear on the action screen. Approve or decline, as appropriate. Follow up with Licensed Professional, as necessary, should the order need to be edited. Enter and approve all paper orders for tracking purposes and route to Medical Records, to be sent for physician signature. Ensure any corrections are made by the Licensed Professional who wrote the order prior to entering the order. Update the patient's medication profile and schedule as applicable; via the order. Ensure all orders that address frequency have appropriate calendar modification completed. Follow up on orders from the Order Tracking Report when the MRS is unable to retrieve the unsigned order. Review and follow up on entitlement verification issues. Review On-Call Coordination Notes, reported every Monday. Follow up on identified deficiencies related to the Prebill audit by 5:00 p.m. on the day following receipt of the Billing Claims Held Report. As each deficiency is cleared, indicate what the deficiency was by updating the patient record. Verifies/ensures there are orders for requested Medical Supplies. Enter Non-Admit information into HCHB with details in Coordination Notes, if no visit was made. Run and submit the Notification of Missed Visits to physicians weekly. Verify benefits and obtain authorization for services on all Medicaid and insurance patients. Review entitlement verification issues, should they appear on the action screen. Document action in Coordination Notes. Review and process all wound score deviations documenting any action and/or follow-up. Review and process vital sign alert reports. Document action, any follow-up and physician notification. Act as back up for the Scheduler in rescheduling missed and declined visits and processing reassigned and reschedule request to ensure timely completion of these tasks. If the Scheduler is not an LPN, receives lab reports and assesses for normality. Forward lab reports to the Scheduler for faxing to the physician. Function as staff nurse PRN. Update Homecare Homebase and computer software, as necessary. Adhere to and participate in the Agency's mandatory HIPAA Privacy Program and Employee Compliance Program. Read and adhere to all Agency Policies and Procedures and follow Employee Handbook Guidelines. Attends inservices, seminars, or other meetings as assigned by the immediate supervisor or other management. Maintains confidentiality of information related to business practices, business activities and personnel. Participates willingly with special projects and overtime work when requested. Maintains a professional attitude when working with staff, fostering the team philosophy and team environment for all personnel. Always provides proper notification and/or advance notice for absence or tardiness without abuse. Does not allow personal affairs to interfere with scheduled work time. Maintains a professional appearance at all times.

Created: 2026-03-05