Performs care management duties on patients as assigned including: notifying the physician of changes in the patient's condition or progress toward goals, obtaining needed physicians orders, reassessing the patient for recertification, supervision of LVNs and home health aides, attending and documenting case conferences, coordination of care by reporting of significant findings to others on the healthcare team, and planning for, notification of and documenting the discharge of the patient. This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor's diagnosis of disease.