Registered Nurse - Home Care Coordinator

Role and Responsibilities

The Home Care Coordinator (HCC) effectively participates in communication and discharge planning in patient's transition both to and from acute care and home care settings. Collaborate with hospitals to prevent patient rehospitalization. Manage referrals and coordinate safe home care services for patients, in accordance with physician. Accountable for developing positive relationships with referral sources.

Essential Functions

• Cultivate relationships to help physicians and hospitals identify the best Home Care solution for their patients.
• Exhibit active listening skills in order to conduct a comprehensive assessment including physical, psychosocial, and anticipated environmental needs.
• Interview patient and family / designated back-up.
• Communicate with PCP to safely transition to home and secure follow up appointment with PCP within seven (7) days of hospital discharge.
• Obtain a copy of the patient's Hospital Discharge Instructions to facilitate medication reconciliation with physician.
• Collaborate with the acute care setting's interdisciplinary team members to facilitate referrals and resulting in timely sharing of patient information during transitions to and from home care.
• Provide accurate and timely documentation via HomeCare HomeBase (HCHB) to facilitate the referral process.
• Develop an initial plan of care for each patient.
• Obtain insurance authorization and verify physician signing home care orders.
• Document according to facility / agency regulatory guidelines.
• Function as a team with fellow HCCs, agencies, and other HCR departments.
• Invoke the nursing process, identify qualifiers for home care, provide sufficient overview of both hospital course and identified initial home care need.
• Assist others as needed, displaying flexibility and effective problem-solving techniques in response to fluctuating patient volume and vacation coverage.
• Effectively communicate with internal business partners to ensure a safe, effective home care plan for all HCR patients.
• Attend required HCR meetings, in-services, and functions.
• Conduct education activities with physicians and hospitals.
• Be knowledgeable and conversant in all HCR programs and services, including specialty programs.
• Work in conjunction with community outreach staff, as needed.
• Meet agency referral metrics.
• Use outreach tools to effectively communicate with referring sources.
• Ability to clearly articulate an understanding of reimbursement issues and their relationship to home care.
• Demonstrate continuous professional development and participation in self and peer evaluation.
• Other duties as assigned.

This job description reflects management's assignment of essential functions; and nothing in this herein restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Education Requirements

Qualifications and Requirements

Work Environment

The Home Care Coordinator is primarily in an office setting and may be exposed to outdoor conditions.

The working conditions are classified as light work :

Physical Requirements

The following is a description of the physical requirements on a daily basis for the Home Care Coordinator. While performing the duties of the job the employee is regularly expected to :

This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed as assigned.

EOE / AA Minority / Female / Disability / Veteran