**PLEASE NOTE: This is an RN position that involves NO direct patient care.** The Care Coordinator for Home Care is a RN responsible for coordinating care for patients receiving skilled interventions in the home setting. Functions include intake referral coordination, case management, evaluation of the creation of the plan of care for patients, referral and coordination of services in the agency and the community, advocacy for the patient in obtaining/attaining goals and intervention of the highest standard, discharge planning, clinical safety education to patient families, coordination of care with third party agencies, and in providing the communication link between the hospital, case management team, and the patient's family. The Care Coordinator facilitates those functions associated with meeting patient needs after discharge from an acute episode of care, specialty clinic, or at the request of the patient's primary care physician. This is a position that is best suited for RNs with experience with high acuity patients in an inpatient setting.
- Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field.
- Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organizataion in the market.
- Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements.
- Solves complex problems and takes a new perspective on existing solutions; exercises judgement based on the analysis of multiple sources of information.
- Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies.
- Works independently, receives minimal guidance.
- Explains difficult or sensitive information; works to build consensus.
- Coordination of Care: Complete case management services between the patient home and the hospital, ambulatory clinic(s), physicians, and other service providers through written progress reports, and case management initiatives from the point of home health referral through discharge. Will also assess the status of patient's plan of care and coordinate communication with necessary medical professionals to obtain new orders, prescriptions, labratory tests, etc. Assist patient families in accessing care and social services outside the home care department. Making referrals to community-based social service agencies when families need assistance and services beyond what Children's Health Home Care offers. Help families maintain insurance coverage by providing information about state waiver programs available and general processes to maintain insurance coverage.
- Communication: Communicate patient needs to appropriate professionals (i.e. social work, clinical pharmacist, clinical dietician); follow-up on communication. Communicate continually with patients and families, physicians, multidisciplinary team members and payers to facilitate coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum. Listens to customer needs and responds in a courteous and tactful manner. Provides timely feedback to the customer in a clear and concise manner.
- Clinical Management/Education: Collaborate with discharge planning team to process referral, establish treatment milestones and ensure home care is the Right Place, Right Time, Right Care setting for the patient. Educate the family on patient's status at time of discharge and prepare family to transition to home care servies. Review home care orders with family to ensure understanding and compliance to increase patient safety once in the home setting. As needed assist in assessing patient's home setting , available caregiver(s), and/or living arrangements to determine if physician's orders for treatment can be adhered to within the patient's home. Participate in the development, implementation, evaluation and ongoing revision of the plan of care, clinical pathways and initiatives to improve quality, continuity and cost effectiveness.
- Knows, understands, and abides by the policies and procedures of CHST, Joint Commission, and DADS.
- Escalates customer concerns/complaints appropriately. Maintains thorough and ongoing communication with staff regarding visit schedules to maintain start of care visit, plan of care orders and recertification requirements.
- Process and Performance Improvement: Work collaboratively with other departments and services to define and study areas of inefficiency and participate in process improvement projects. Be involved in the development of strategies and plans to maximize the most appropriate use of services in assigned areas.
- Ability to meet physical and non-physical demands as outlined in the job description is an essential function of the job.
Education and Experience:
- BSN - Required
- RN license in the state of Texas - Required
- BLS CPR - Required
- Certified Case Manager - Preferred
- Acute Care or Inpatient experience - Preferred