Job Description

The clinical team manager is responsible for managing, supervising, coordinating, evaluating, and developing client care teams to ensure quality care delivery and appropriate case management within Brooks Rehabilitation’s scope of services and policies; state, federal, and local laws; and Nurse Practice Act. Responsible for the oversight of personnel and all patient care services provided. The CTM may at times provide direct patient care to patients by utilizing the nursing process and accepted standards of practice. Participates in and is an active member of the patient’s interdisciplinary treatment team. The CTM also directly supervises the patient care team and assists to implement the patient's plan of care.

Job Responsibilities:

• Manages and directs a team of Nurse and Therapist Case Managers ensuring safe, effective, and appropriate home care services.
• Is available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients.
• Coordinates and receives referrals, determines services required, and Brooks Rehabilitation’s ability to meet needs. (484.105(c)(3) Facilitates making patient and personnel assignments. (484.105(c)(1)
• Coordinates patient care. (484.105(c)(2)
• Meets with Case Managers/clinical staff on a regular basis to provide guidance and information related to specific issues.
• Assures the development, implementation, and updates of the individualized plan of care. (484.105(c)(5). Provides direction to teams to assure that client needs are met and services are provided according to the plan and current clinical practice guidelines and professional standards.
• Assists clinical staff in establishing priorities, setting goals, and evaluating progress toward goals.
• Leads case conferences and other clinical meetings to facilitate coordination of care and assures patient needs are continually assessed. (484.105(c)(4)
• Collaborates with Brooks Rehabilitation Leadership in identifying operating budget needs and priorities for the department
• Reviews weekly team members’ productivity information
• Coordinates 24-hour Agency coverage by Registered Nurses. Evaluates quality of on-call services
• Provides on-call coverage as needed
• Provide direct patient care in the field in accordance with the RN job specifications.
• Develops working relationships with other health care professionals in the community.
• Provides support and direction to Agency staff, other health care professionals, clients, and families related to appropriate and available health care resources
• Educates Agency staff on clinical services, policies, and procedures as needed
• Facilitates problem-solving sessions to enable Case Managers and other staff to resolve client and/or reimbursement source issues
• Stays current on available community resources, health care costs, and industry trends through self-education and access to outside educational opportunities
• Ensures accuracy, completeness, and timeliness of clinical documentation in accordance with Agency policies and procedures, regulatory requirements, and industry standards
• Monitors open and closed charts regularly, and participates in the quarterly clinical record reviews and QAPI activities.
• Reviews Agency policies and procedures and recommends changes or revisions as needed
• Provides educational programs and information regarding appropriate documentation practices
• Provides leadership to team and support staff in identifying Agency/client needs and opportunities for quality improvement
• Assists with marketing, public relations, and discharge planning by participating in departmental meetings
• Assists quality improvement teams with data collection for the Quality Assessment and Performance Improvement Plan established by Brooks Rehabilitation
• Reviews OASIS data collection to assure accuracy and consistency with requirements. Communicates with clinicians and provides training as indicated to achieve compliance with collection and reporting timelines
• Oversight of Teams clinical outcomes and process measures. Actively implements measures to improve outcomes including those identified in the QAPI program.
• Identifies and implements changes in clinical and/or operational practice based on the findings of the QAPI Program
• Interprets and enforces human resource policies and procedures in a fair and consistent manner
• Assists in the screening and interviewing of new Agency personnel and makes recommendations to Director of Nursing. Assists in the orientation of new personnel.
• Conducts timely performance evaluations in accordance with Agency policy
• Provides on-site supervision per Agency policy and as needed to determine staff competency and respond to educational and developmental needs
• Follows Agency guidelines for disciplinary actions. Documents all disciplinary actions in accordance with Human Resource policies and legal guidelines
• Monitors employee turnover, overtime, and absenteeism. Takes appropriate actions to address problems/issues
• Collaborates with Agency DON and other clinical management staff to ensure proper staffing of qualified, competent personnel
• Promotes personal safety and a safe environment for clients and co-workers
• Demonstrates knowledge of safety/infection control practices by compliance with policies and procedures and regulatory requirements
• Assesses safety of environment and takes the initiative to help prevent accidents and promote safety
• Recognizes and responds appropriately to potentially unsafe situations
• Performs other duties as assigned
• Maintain a working knowledge of commonly used medical equipment/devices.
• Respects confidentiality of information in the client clinical record and only shares this information in accordance with Agency policy and HIPAA
• Educate patients and families on medications, conditions and services.
• Responsible for ensuring that the standards of clinical practice are being followed at all times and the development, implementation and updates of the individualized plan of care.
• Acts in a professional manner, work as scheduled and report to work on time.
• Works with the Director of Nursing to ensure that Medicare guidelines and revisions are being followed.
• Follow procedures to work within the frame of the law.
• Keeps the Director of Nursing or Administrator apprised of any problems or potential problems.
• Meet with the nurses, therapists, home health aides and other disciplines involved in the patient care for case conference on a weekly basis.
• Takes and writes physician orders as necessary and appropriate.
• Establishes and maintains an ongoing relationship with the physicians and their office staff, facilities, or other members of the community involved to promote continuity of care.
• Represent Brooks Rehabilitation at all times in a professional and loyal manner.
• Attend meetings, luncheons and in-services as needed.
• Provide guidance to Clinicians and Staff as needed.
• May perform other duties as assigned.

Job Qualifications:

• Graduate of an accredited school of professional nursing; BSN preferred.
• Registered Nurse with current/valid Florida Nursing license and approved Hands-On CPR certification.
• A minimum of two-years experience as a registered professional nurse and one year of supervisory experience desired, preferably in the area of home health care.
• Demonstrates organizational and leadership ability.
• Demonstrates a working knowledge of Medicare guidelines for home health coverage and compliance.
• Must have good verbal and written communication skills and evaluation techniques and demonstrate knowledge of clinical skills, judgment, current nursing practices and analytical capabilities.
• Knowledge of reimbursement sources and documentation requirements within home health care.
• Must be familiar with Medicare, Medicaid, and other third-party payer guidelines.
• Must have a current/valid driver’s license, agency-required automobile liability insurance, and availability of personal, dependable transportation to conduct home visits.
• Able to assess patient status and identify requirements relative to age specific needs.
• Participate in the development of agency policies.
• Ensures care is provided in accordance with current clinical practice guidelines and quality outcomes
• Current CPR certification
• Hands-On BLS

Brooks Rehabilitation, a nonprofit headquartered in Jacksonville, Fla., has been a comprehensive system of care for physical rehabilitation for more than 50 years. Ranked by U.S. News & World Report as the No. 1 rehabilitation hospital in Florida and top 20 in the nation, Brooks operates three inpatient hospitals in Florida and is set to expand its reach with a new hospital on Mayo Clinic's Arizona campus in 2026. Through its commitment to innovation, Brooks is at the forefront of cutting-edge research, education and technology advancing the science of rehabilitation. Brooks provides outpatient services in more than 50 locations, offers skilled nursing, home health, assisted living and memory care along with community programs and services to improve the quality of life for people living with physical disabilities.