Job Description

The Clinical Care Manager serves as the clinical point of contact for a caseload of home care clients, their families, and assigned caregivers. This role blends nursing judgment with hands-on care coordination, functioning as the first line of triage for medical concerns, caregiver performance issues, scheduling conflicts, and interpersonal challenges that arise in the home care setting. The ideal candidate is a licensed nurse (RN) who can move fluidly between clinical assessment, conflict resolution, and administrative problem-solving — often within the same phone call.

Key Responsibilities

Clinical Triage & Medical Support

• Serve as the first point of contact for incoming clinical calls; triage symptoms and determine appropriate level of urgency and response.
• Evaluate and respond to reported changes in condition, including vital sign abnormalities (e.g., low or high blood pressure), altered mental status (AMS), suspected UTIs, suspected yeast infections, rashes, and other new or worsening symptoms.
• Provide guidance following incidents such as patient falls, including assessment recommendations, escalation to EMS/physician when warranted, and documentation.
• Answer patient and family medical questions within scope of nursing practice, escalating to a physician, on-call nurse, or appropriate provider when outside scope.
• Apply clinical nursing judgment to evaluate medication administration decisions against current vital signs and prescriber-established parameters (e.g., withholding an antihypertensive when a client's blood pressure falls below a specified threshold), and determine appropriate next steps, including physician notification, when a dose is held or missed.
• Ensure all medication administration and medication assistance performed by home health aides and CNAs complies with the Florida Nurse Practice Act (F.S. 464.0156), F.S. 400.488–400.489, and applicable Florida Administrative Code provisions (64B9-14), including confirming that only properly delegated, trained, and competency-validated unlicensed personnel administer or assist with self-administered medication, and that no unlicensed staff administer Schedule II–IV controlled substances.
• Conduct or oversee the registered nurse review and medication reconciliation required before a home health aide or CNA may assist with self-administration of routine medications, per F.S. 400.488, and ensure appropriate written consent is on file.
• Monitor and respond to antibiotic administration questions, including timing, missed dose protocols, and observed adverse reactions or lack of therapeutic response, escalating to the prescribing provider as needed.
• Provide ongoing case oversight for general medication management concerns — including polypharmacy, refill/access issues, and caregiver or family confusion about the medication regimen — consistent with the client's individualized plan of care.
• Coordinate with providers, dialysis centers, and outside agencies regarding appointment changes, missed or rescheduled treatments (e.g., changed dialysis appointments), and care plan updates.
• Communicate and collaborate with tribal case management, insurance case managers, and other external stakeholders regarding client care plans and authorizations.

Caregiver Oversight & Coordination

• Address and resolve concerns related to caregiver performance, including caregivers not preparing meals, not completing light housekeeping duties, leaving a patient unattended, refusing to drive, or calling out on short notice.
• May assist with managing last-minute caregiver call-offs by identifying and dispatching replacement coverage to avoid gaps in care.
• Investigate and mediate reported personality or compatibility conflicts between clients and caregivers.
• Support caregivers in navigating scheduling and care delivery challenges, including animal-related concerns in the home (e.g., pets affecting caregiver safety or ability to perform duties).
• Provide assistance processing and managing client requests to remove or replace a caregiver, ensuring continuity of care during the transition.
• Train and support caregivers on use of the AlayaCare (or comparable EVV/scheduling) system; troubleshoot system access and documentation issues.

Communication, De-escalation & Family Support

• De-escalate and professionally manage interactions with angry, upset, or difficult patients and family members.
• Respond calmly and empathetically to patients who are being verbally difficult ("mean") or resistant to care, using de-escalation and therapeutic communication techniques.
• Manage family expectations, including situations where family members request additional attention or support for themselves in addition to the client.
• Maintain clear, professional, and timely communication across all parties — clients, families, caregivers, providers, and internal staff — both verbally and in writing/documentation.

Documentation & Compliance

• Document all clinical assessments, incident reports, communications, and care plan changes accurately and promptly in accordance with agency policy and regulatory requirements.
• Ensure care plans remain current and reflect any changes in client condition, caregiver assignment, or service needs.
• Maintain compliance with HIPAA and all applicable state/federal home care regulations.

Requirements

• Active, unencumbered nursing license (RN or LPN/LVN) in the state of practice.
• Minimum of 2–3 years of clinical nursing experience; home health, hospice, or care management experience strongly preferred.
• Working knowledge of common geriatric and chronic conditions (hypertension, UTIs, altered mental status, skin/wound issues, etc.).
• Experience with electronic visit verification (EVV) or care management software (e.g., AlayaCare) preferred.
• Strong triage and clinical decision-making skills, with sound judgment on when to escalate.
• Demonstrated ability to de-escalate emotionally charged situations with patients, families, and staff.

Core Competencies

• Clinical Judgment: Able to quickly assess symptoms and determine appropriate action, from self-resolving issues to emergency escalation.
• Critical Thinking & Problem-Solving: Comfortable managing multiple, often unrelated issues (clinical, interpersonal, logistical) in a single shift.
• Empathetic & Professional Communication: Communicates with warmth and patience under pressure, while maintaining clear boundaries and professionalism.
• Flexibility & Adaptability: Able to pivot quickly between a medical emergency, a scheduling conflict, and a family complaint without losing composure.
• Conflict Resolution: Skilled at mediating disputes between clients and caregivers, and de-escalating angry patients or family members.
• Organizational Skills: Manages a high volume of concurrent issues, follow-ups, and documentation requirements.
• Technology Proficiency: Comfortable learning and troubleshooting scheduling/EVV platforms and supporting caregivers who struggle with the system.

Working Conditions

• Primarily remote, with potential for occasional in-home visits.
• Requires availability to respond to urgent client or caregiver issues after normal business hours.
• Fast-paced environment requiring the ability to manage frequent interruptions and shifting priorities.