RN Care Coordinator-Home Care

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

About Duke HomeCare & Hospice

 

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

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

Job Summary
The Care Coordinator is responsible for the assessment and coordination of home health, hospice, and infusion services for the hospitalized patient, clinic/outpatient and/or patient in an alternative setting (i.e. extended care facilities) by acquiring admission information and assessing for the appropriateness of home care services. The role functions as an integral part of an interdisciplinary team, ensuring excellence with the transition of care facilitate the patient to achieve optimal clinical outcomes once in their own home. Responsible for providing community education, responding to customer requests and concerns, and interfacing with referral sources, organizations, government agencies and third party payors.

MAJOR JOB RESPONSIBILITIES

Clinical Care Coordination
1. Utilize comprehensive assessment skills to determine a patient’s appropriateness for home care, initiate the appropriate home program referral, and provide patient/family education related to the initiation of home care services.
2. During patient/family education, identify any barriers or concerns related to home care by addressing the total individual inclusive of medical, psychosocial, behavioral and spiritual needs. Communicate the identified concerns to the Case manager or physician team to develop a comprehensive discharge plan.
3. Provide ongoing daily assessment and monitoring of patient referrals until discharge to ensure all patients have the appropriate services including ongoing home support. Coordinate with the hospital Case Manager to request additional services/orders.

4. Maintain effective communication with the health care team related to assessment findings, additional discharge planning needs and during patient/family education.
5. Electronically document all activity in Maestro, Netsmart, HCN360 and other documentation systems relevant to the position.
6. Meet with referral sources regularly to identify gaps in care, patient population needs, opportunities for referral process improvement and ongoing identification of additional patient/staff educational opportunities.
7. Maintain a working knowledge of specific insurance benefits, reimbursement guidelines and maintain an understanding of their impact on the delivery of home health, hospice, and infusion services.
8. Maintain a working knowledge of applicable federal and state regulatory guidelines related to home care services
9. Maintains current knowledge base of the comprehensive services, products and supplies available through DHCH.
10. Maintain an updated record of referral source/community contacts and assist with the analysis and identification of referral trends and needs.
11. Work with DHCH referral center, finance, and the appropriate home program to accurately complete and obtain any additional required documentation to facilitate the prevention of an insurance denial for services.
12. Develop and maintain a positive relationship with internal and external customers.
13. Job responsibilities may include site-specific duties, weekend/holiday or after hours coverage as designated at each entity.
14. Perform other related duties incidental to the work described herein.

 

Educator
1. 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.
2. Assists in the coordination of home discharge plan and facilitates the transition to the hospital care coordination team.
3. Serves as an expert in supporting access to internal and external resources for patients.