RN, Home Care Coordinator

The Home Care Coordinator is responsible for developing home care plans for referred hospital, rehab, or skilled nursing facility (SNF) clients. This role acts as a vital bridge between Nascentia Health and healthcare facilities, balancing patient advocacy with company operational needs. HCCs manage the complete intake and referral pipeline—utilizing clinical expertise to ensure thorough chart preparation, facilitating case conferences, and conducting targeted bedside evaluations to secure safe, efficient transitions of care. And acting as a vital relationship manager and primary liaison between Nascentia Health and hospitals, rehabs, and/or SNFs

Performance Responsibilities and Standards:

1. Promote continuity of care for referred clients.
   1. Assist in the development of a home care plan, including the arrangement of services, supplies, and appliances needed.
   2. Review home care policies and procedures with clients/families, physicians, agency care providers, insurance providers, and service and equipment vendors as indicated.
   3. Round daily in hospitals and facilities that allow regular floor access; for facilities that do not allow regular rounding, make every effort to see complex patients bedside once accepted and/or to facilitate acceptance.
   4. Manage referrals strategically to ensure they serve the best interest of the patient, family, and referral source, while aligning with the needs, priorities, and capabilities of the company.
2. Promote quality assurance as it relates to home care planning.
   1. Utilize clinical skillset to ensure charts and information are complete, thorough, and that all pieces needed for the Start of Care visit are present in the chart and attached documents.
   2. Document home care eligibility per Nascentia Health policies and procedures and Department of Health guidelines.
   3. Act as a resource and/or consultant to hospital or SNF staff regarding home health services.
   4. Facilitate and participate in team conferences and case conferences when appropriate between client/family, physician, hospital staff, and home care agency staff.
   5. Work closely with Referral Center RN Team Leader for support in maintaining referral expectations within the agency’s daily and future capacity projections.
3. Additional Responsibilities as requested.
   1. Participate in agency committees.
   2. Present teaching and education to patients, caregivers and providers about Nascentia Health Homecare, their mission and services available.
   3. Perform all other duties as assigned.

Requirements:

1. Current license to practice as a Registered Professional Nurse/ Medical Social Worker in New York State or degree in a health-related field.
2. Minimum one (1) year home health care experience preferred.
3. Sales experience a plus
4. Current New York State driver's license and automobile insurance required.
5. Excellent verbal communication skills required.

Physical Requirements:

1. Visual/hearing ability sufficient to comprehend written/verbal communication.
2. Requires standing or walking approximately 75% of day.
3. Hearing/speaking ability sufficient to communicate on the telephone and with families, physicians and hospital staff.
4. Ability and willingness to drive in all kinds of weather conditions to make facility visits.
5. Option of occasional working from home dependent on facility guidelines and rules.
6. Bloodborne Pathogens Exposure Category I – Employee has tasks that routinely involve exposure or potential exposure to blood, body fluids or tissues.

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.