Visiting Nurse Health System

Manager

• Conduct in-home or facility-based assessments of clients to determine appropriate services
• Collaborate with SW Care Managers and interdisciplinary teams on level-of-care decisions
• Develop care paths and discharge plans based on client needs, condition, and support systems
• Complete and document assessment tools such as GDS, MMSE, and fall risk assessments
• Schedule and perform timely assessments, reassessments, and follow-up per DCH policy
• Coordinate transitions from hospital to home/community settings
• Document care plans, hospitalizations, care transitions, services, and case notes per DCH and VNHS standards
• Approve services within established funding limits and ensure clinical appropriateness
• Participate in interdisciplinary team meetings, training sessions, and quarterly network events
• Support infection control practices and maintain confidential client records

Care Manager, LPN