Performs care management duties on patient whose primary skilled service is physical therapy to include: SOC documentation, preparing written Plan of Care for the Certified Home Health Aide if applicable, notifying the physician of changes in the patient's condition or progress toward goals, reassessing the patient for recertification, supervision of the home health aide, attending and documenting case conferences, initiating coordination of care by reporting 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.