Agency: Beaumont Home Health and Hospice Our culture and people are what set us apart from other post-acute care providers. We’re dedicated to the growth and development of our team to set them up for success. We CARE for our patients like they are our own FAMILY. Note: The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), require COVID-19 vaccinations for all Medicare and Medicaid certified providers. Based on this regulation, all of our employees must be fully vaccinated or have a valid exemption. Currently offering a $5,000 SIGN ON BONUS! Schedule: Monday through Friday 8:00 am to 4:30 pm Location: Corewell Health Troy Hospital HOW YOU'LL MAKE A DIFFERENCE: At our agency, we care for patients where they spend the majority of their time – in their homes. This privileged position allows us to see things that are invisible to a patient’s primary care or hospital physician, and to deliver the best possible care tailored to each patient’s setting. As a Post-Acute Care Coordinator (PACC) the work you do every day makes a difference in the lives of our patients by providing patient healthcare coordination services. You will attend discharge/multidisciplinary rounds in acute care, ambulatory and/or other settings within the health system to share your expertise and to assist the patient in transition of care from one setting to the next within the health system. WHAT WE OFFER: We provide medical, dental, and vision insurance with flexibility for you to select what works best for you. Eligible teammates receive paid time off and may participate in the 401K, if they choose. Historically the company has matched 401K contributions which helps build your nest egg even faster. Finally, our benefit program includes company paid life, disability insurance, and a robust Employee Assistance Program. HOW YOU'LL WORK: You’ll serve as a resource for patients to determine home care eligibility. You will also assist the organization in identifying future patients. You'll be responsible for all practices and duties within the scope of practice outlined by the state. MAJOR AREAS OF RESPONSIBILITY: Compliance: Determine home care eligibility and review patient insurances and medical documentation. Patient Care: Coordinate health care services as ordered by the attending physician. Discharge Planning: Assist hospital/facility personnel in the discharge planning process. Minimize Patient Risk: Ensure coordination of all ancillary services per the patients’ needs following discharge. Promote well-being of patients. Customer Service: Increase awareness of services offered and service account(s) to maintain facility relationships. Build and maintain lasting positive relationships with patients/clients and facility/hospital personnel, physicians and other team members. Patient Advocate: Function as a resource nurse/social worker for your patients. Policies: Review and complete all clinical documentation following agency protocol and Medicare/Federal guidelines. Collaboration: Participate in care conferences and coordination of case management. Notify the referring facility manager before contacting patients. Operations: Participate in Care Integration meetings. HARD & SOFT SKILLS: Compassionate communicator with a positive attitude Patience is a virtue when working with patients, families, physicians, and coworkers Attention to detail is critical, as is being observant and following directions REQUIREMENTS: Registered Nurse or Licensed Practical Nurse with current license in the state of employment. Registered Nurse is highly preferred. Minimum of two years of experience. Home care experience preferred. Valid driver's license and auto insurance in your name as a driver. Capable of all physical demands. We are proud to be part of the Alternate Solutions Health Network family. Troy, MI We’ll help you put your passion for patient care to work. Apply today! This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. We are an Equal Opportunity Employer. Beaumont Home Health and Hospice is a partner with Alternate Solutions Health Network. Post-acute care is at the center of improving health outcomes. We care for patients where they spend the majority of their time – in their homes. This privileged position allows us to see things that are invisible to a patient’s primary care or hospital physician, and to deliver the best possible care tailored to each patient’s setting. As the healthcare industry continues to evolve away from hospital-centric care, our work, caring for patients in their homes becomes more important than ever. Our success helping patients recover comes from engaging with them. We start at the facility bedside and coordinate each patient's transition back to their home, ensuring a smooth transition and that their care plan is right for them. We support complex, high-acuity, medically-at-risk aging patients. This is the most challenging group of individuals to serve, and we find it the most rewarding. And we do this all in partnership with health systems. Together we create a seamless care environment that enables patients to receive excellent care in the setting that best meets their needs.