Job Summary

Responsible for coordinating with the medical team, Clinical Care Managers, and other disciplines associated with transition to facilitate optimal health outcomes and successful, seamless transitions along the healthcare continuum. The Coordinator uses critical thinking, interpersonal skills, communication, as well as assessment tools to determine continuing care service’s needs, as well as community resource service needs. This position is a key member of the multi-disciplinary rounds team and works to coordinate such post-acute services and ensure that all needed services are arranged and in place prior to the transition. Responsible for educating patients and their families/caregivers about the services that are to be received.

Essential Functions

• Functions as a liaison for patient/family in navigating the continuum of care.
• Assesses, plans, coordinates, and evaluates services of patients with the goal of equipping and empowering individuals and their families to easily assess resources and adopt healthy lifestyles that will increase their ability to remain healthy at home or in the least restrictive environment.
• Works closely with hospitals, clinics, health care facilities, and agency clinical and administrative personnel to ensure patient care is seamless, efficient, effective and appropriate to the individual.
• Interacts daily with patients, medical professionals, and the community to achieve continuity of care, coordination of medical services, and to document plans of care as related to home health care and hospice services.
• Makes on-site consultative, educational visits in the hospital to evaluate the appropriateness of the patient’s admission to continuing care services. Able to complete needs assessment considering psychosocial, physical, economic, and health literacy factors.
• Uses interpersonal skills and excellent communication skills to establish a rapport with the patient and forecast and prioritize his/her needs.
• Receives referrals and orders from physicians, hospital, and other agencies. Acts as a resource for clinical personnel.
• Completes accurate and appropriate documentation, logs, and/or patient forms and records to ensure compliance with regulations, agency policy, payer requirements, and standards of care.

Physical Requirements
Works requires walking, standing, sitting, lifting, reaching, bending, and stooping. Must lift a minimum of 35 pounds shoulder high. Must speak English in effective, comprehensible terms. Ability to communicate verbally and in writing. Must have intact sense of sight and hearing, finger dexterity, critical thinking, and ability to concentrate. Must be able to respond quickly to changes in assignments. Ability to travel between facilities and hospital units.

Education, Experience and Certifications

Graduate of an accredited school of nursing required. BSN preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or; if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works required. Minimum of three years nursing experience preferred. Prefer two years in acute health care inpatient setting; home health, managed care, hospice, or case management. Current driver’s license.