Home Health RN Transitions Coordinator

Represents Interim Healthcare by working collaboratively with the patient, patient’s family, the acute care hospital or sub-acute facility, physician group or health plan staff to facilitate a safe and effective transition to home care.

Essential Functions:

Assess the patient’s and family caregiver’s homecare needs and coordinates home health care services as required prior to the patient’s transition home.
Obtains necessary medical information regarding the patient’s health status, current medications and goals of home care intervention from designated inpatient or care manager staff.
Acts as clinical resource to coordinate complex cases for safe and appropriate transition to the patient’s home.
Attends all Quality Improvement meetings with hospital or setting staff as required.
Attends all required Interim HealthCare Office meetings to enhance team communication, coordination of services and quality of care.
May coordinate additional services to assist client and family during the transition, as appropriate.
Reviews Interim HealthCare’s policies and services with referred patients and / or family caregivers or authorized patient representative.
Makes calls to patients post discharge to coordinate services and review discharge instructions.
Makes calls to primary provider in the community to ensure that patients have attended follow up appointments.
Communicates with the Intake nurse and the Clinical Manager to determine staffing capabilities.
Communicates essential patient information to home care clinicians who will be initiating care.
May assist with obtaining Physician orders as required.
Responds to inquiries regarding home care services and programs to accurately identify the needs of each patient.
May have access to and use of personal health information (“PHI”) as necessary to fulfill the above duties and responsibilities.
Performs all functions in compliance with federal, state, local law and regulation, as well the policies, procedures, and practice standards of Interim HealthCare.
Assists with Insurance eligibility and authorization process, when appropriate.
Performs other duties as assigned.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS:

Valid Registered Nurse License in the State of IL
Two years nursing experience
One year of home care experience, home care intake experience or case management experience
Prior liaison or sales experience preferred

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