RN Care Coordinator for HomeCare, Hospice & Infusion Services at Duke Univ. Hospital

Duke Homecare & Hospice Duke Homecare & Hospice offers hospice, home health and infusion services as well as serves as the home for the Duke Caregiver Support Program. Our Hospice team works closely with a patient's physician to provide comprehensive, individualized care in the comfort their home or at our inpatient hospice facility located in Durham. Our team of nurses, therapists, social workers, counselors, and chaplains help patients and their families manage advanced medical conditions. Duke Home Health provides services in a patient's home that include skilled nursing, physical therapy, occupational therapy, speech therapy, social service, home health aides, and pain and wound management. Our infusion team comes to a patient's home to administer intravenous medications, including antibiotics and chemotherapy, to children and adults. Our nurses, pharmacists, dietitians, and patient services coordinators work under the direction of a patient's doctor to monitor needs and treatment.

To have the opportunity to speak to someone further about this position, please click this link to schedule with a recruiter: https://calendly.com/jacqueline-huff/homecare-hospice-information

The DHCH Care Coordination team consists of 12 RN Care Coordinators (RN-CC) working across the 3 Duke hospitals. As a coordinator, you will have the opportunity to work closely with the hospital team to include the Case Manager, and Physician to initiate home care services for those patients who need home health, hospice, or infusion services at discharge. We provide education to the patient and their caregiver related to the services needed to facilitate an appropriate discharge plan. The RN-CC will utilize their strong assessment skills and clinical knowledge in order to fulfill our goal to provide the patient/family with a smooth transition to home.

Shift: Monday to Friday 8:30 AM-5:00 PM. Rotating weekend shift coverage as needed every 4-6 weeks.

Job Summary:

Clinical Expert

• Collaborates with providers, case managers, registered and other members of the health care to assess patient needs, develop a plan of care and optimize healthcare outcomes.
• Provides triage support the patient populations across multiple clinical areas. Monitors patient outcomes and documents patient response to care. Ensures providers are informed on outcomes.
• Serves as the point of contact for their patient population, or the care team to manage complex health needs.
• Provide patient consultations and information on recommended treatments.
• Coordinates prescription refill management, including creation and submission of prior authorization forms.
• Completes clinical paperwork including lab, school, and leave forms, medical releases, emergency, and travel letters, durable medical equipment, etc.
• Assist in coordinating complex patient visits. Supports patients through pre-visit clinical assessments, to include collection of appropriate history.
• Participate in Quality Assurance/Performance Improvement (QAPI) activities as requested.

Educator

• Provides education to the patient and caregiver related to the services needed to facilitate access to care with Duke Health; disease state; and interventions to support health status.
• Assists in the coordination of home discharge plan and facilitates the transition to the hospital care coordination team.
• Instructs patients and families regarding treatments, procedures, medications, and continuation of care.
• Serves as an expert in supporting access to internal and external resources for patients.

Care Coordinator

• Supports with procuring necessary medications and coverage options, and treatment equipment.
• Coordinate internal and external referral appointments.
• Coordinates post-hospitalization care and discharge planning.
• Collaborates with inpatient teams to support discharge plans.
• Assists patients and patient care givers with education on cost of service, insurance coverage, and payment options with the patient.
• Assist care team with setting goals for quality assurance and best practices.
• Provide community resources and referrals for continuing care.
• Provide clinical consultation answers for patients and patient support.
• Ensure compliance with professional standards & regulatory requirements.
• Investigates coverage of the newest medications/therapies.
• Completes disability, or other pre-inpatient and discharge forms.
• Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required.

Required Qualifications at this Level

Education

BSN Required

Experience