Clinical RN Manager- Integrated Care

FlexStaff is looking for a Clinical Nurse Managers in a variety of locations within New York.

The Clinical Manager - Integrated Care plays an essential role in ensuring that participants in contracted organizations experience smooth and effective transitions from hospital to home, helping to reduce hospital readmissions and improve health outcomes. This role provides direct care, participant education, and coordinates with interdisciplinary teams (IDT) to enhance participant outcomes during the post-discharge period. The Clinical Manager also supervises home care staff, ensures compliance with clinical standards, and ensures that participants receive appropriate, high-quality care at home.

This position combines oversight of the clinical care of contracted organizations provided at participants' homes with leadership in care transition planning and execution. The Clinical Manager collaborates with hospital discharge planners, physicians, and home care staff to create and implement personalized care plans for participants, ensuring their health needs are met in alignment with organizational goals and best practices.

Job Responsibilities:

Care Transition Oversight:

Collaborate with hospital discharge planners, physicians, and interdisciplinary teams to develop personalized care transition plans for participants discharged from hospital to home.

Review participants' medical histories, discharge instructions, medications, and follow-up care to ensure smooth, safe transitions.

Ensure that participants understand their post-discharge care plan and provide education on medication management, wound care, and follow-up appointments.

Participant Assessments and Care Coordination:

Conduct comprehensive home visits to assess participants' health, living environment, and support systems.

Monitor participants' conditions during the transition period, identifying any changes or complications that require adjustments to the care plan.

Work with the IDT to ensure comprehensive care coordination and optimize participant outcomes.

Direct Nursing Care:

Provide skilled nursing services in the home, including medication administration, wound care, vital sign monitoring, and support with activities of daily living.

Educate participants and families on managing chronic conditions, preventing complications, and improving overall health outcomes.

Identify early signs of health deterioration and take proactive measures to prevent readmissions.

Supervision and Field Support:

Supervise, instruct, and guide Nurses, Personal Care Aides (PCAs), and Home Health Aides (HHAs) in the delivery of home health care services.

Conduct joint visits with Nurses and other field staff for supervision and competency assessments.

Provide mentorship and guidance, acting as a resource for nursing staff and care teams.

Monitor adherence to care plans and clinical training protocols, addressing deficiencies when needed in coordination with leadership.

Quality and Compliance:

Maintain accurate, up-to-date documentation of participant assessments and care provided, ensuring compliance with PACE, LHCSA regulations, and organizational standards.

Participate in quality improvement initiatives and conduct routine audits to ensure quality care delivery.

Stay informed about current health-related issues, evidence-based clinical practices, and regulatory changes.

Managerial Oversight and Team Collaboration:

Ensure that all clinical team members are adequately trained and provide high-quality care according to best practice standards.

Coordinate with the Care Planning Team to develop and implement care plans based on participant assessments and goals.

Participate in mandatory in-service education and staff development programs.

Support the training department in developing orientation programs for new hires and staff members.

Participant and Family Education:

Educate participants and families about care plans, including medication management, lifestyle modifications, and safety precautions.

Empower participants to manage their health and understand when additional care is needed.

Address participant-specific concerns related to transitioning from hospital to home.

Physical and Cognitive Requirements:

Ability to lift up to 50 pounds, bend, squat, and perform other physical tasks as required for patient care and equipment handling.

Ability to perform administrative duties such as typing and documentation on a computer.

Cognitive ability to make decisions, reason, analyze information, and apply knowledge in clinical settings.

Ability to travel between locations, walk to participants' homes, and work in varied environmental conditions, including outdoor and patient home settings.

Schedule: 8:30 AM - 5:30 PM

Weekly Hours: 40

Qualifications:

Education: Degree from an NLN-accredited nursing school (RN, BSN preferred).

Experience: At least 3 years of clinical nursing experience, including 1-2 years in home care or a similar healthcare setting. Experience in care transitions, case management, or PACE programs preferred.

Licensure: Current active and unrestricted license as a Registered Nurse in New York State.

Skills: Strong clinical assessment and critical thinking abilities, excellent communication skills, and the capacity to manage multiple participant cases effectively.

Additional Requirements:

Ability to travel to participants' homes and work in varying environmental conditions.

Proficiency with computers and electronic health record (EHR) systems.

Experience with long-term care or managed care systems beneficial.

Vehicle and current New York State driver's license preferred.