Job Description

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 escalations 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.
• Monitors 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.

Other Duties

• Performs other related duties as assigned, consistent with licensure, competency, and business needs.