RN, Care Coordinator

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Role:
The RN, Care Coordinator is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Group (IDG), and providing palliative and supportive care to the patient/family unit.

Qualifications:
• Current license as RN in the state where the employee will be working
• Minimum one (1) year of in-patient nursing or hospice experience for external candidates; for internal applicants, minimum of 6-months of LPN experience with hospice/home health within an affiliate
• Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
• Mobile Driver - Valid driver’s license and automobile insurance per Company policy
• Reliable transportation to meet visit schedule
• Ability to use equipment with visual and auditory mechanisms
• Ability to effectively communicate in English (verbal and written)
• Flexible schedule to meet the needs of Hospice House patients
• Ability to manage the emotional stress of working with and caring for terminally ill patients and their families
• Ability to physically access patient rooms, other areas of the Hospice House/Hospital/ALF, etc., and any home (i.e., navigate stairs and narrow spaces, tolerate heat and lack of air conditioning) within any part of the service area
• Ability to perform the essential functions and physical requirements (including, but not limited to: lifting patients and/or equipment, bending, pushing/pulling, kneeling) of the job with or without reasonable accommodation

• Active BLS for healthcare professionals from the American Heart Association or Red Cross. Employees hired prior to 12/31/2022 must obtain certificate prior to 10/1/2023

Some locations may require:

• Provides reassurance on the phone to patients and families. Assists in finding solutions to their questions and/or recognizes the need for an in person visit. Coordinates in person visit when needed/or requested.
• Assists the patient and family to achieve the desired comfort levels.
• Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations.
• Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Group (IDG).
• Completes clinical admissions for all Company services including, but not limited to:
  • Explains services to potential patients/families and addresses questions regarding patient fears, physical limitations, while putting the patient/family at ease; presents services in an empathetic and compassionate manner 
  • Identifies admission objections, concerns or other entry barriers and provides responses
  • Educates patient/family on admission requirements and addresses immediate needs
  • Completes informed consents and initial assessment according to regulations and Company policy
  • Provides information to Physicians and initiates Plan of Care to address patient’s immediate needs
  • Initiates skilled nursing interventions to prevent complications, alleviate symptoms and maximize physical and emotional comfort
  • Obtains Physician orders
  • Completes documentation per Company policy
    • Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public.
    • Communicates frequently with Admissions to ensure timely follow-up.  When assignment is complete, informs Admissions and prepares for next assignment.
    • Provides all necessary clinical communication timely using SBAR.
    • Discusses any potential needs with after-hours staff.
    • Obtains consents for services and arranges safe discharge in an efficient manner for referred and eligible patients while meeting productivity expectations.
    • Obtains medical record information for the referral.
    • Develops strong relationships with case managers, physicians, etc. at facilities.
    • Works with Professional Relations Representatives (PRRs) to provide education on all available services.
    • Provides care for any GIP patients in a hospital including daily visits, professional management, documentation and efficient discharge.

      
      Competencies:
      • Satisfactorily complete competency requirements for this position.
      
      Responsibilities of all employees:
      • Represent the Company professionally at all times through care delivered and/or services provided to all clients.
      • Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
      • Comply with Company policies, procedures and standard practices.
      • Observe the Company's health, safety and security practices.
      • Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
      • Use resources in a fiscally responsible manner.
      • Promote the Company through participation in community and professional organizations.
      • Participate proactively in improving performance at the organizational, departmental and individual levels.
      • Improve own professional knowledge and skill level.
      • Advance electronic media skills.
      • Support Company research and educational activities.
      • Share expertise with co-workers both formally and informally.
      • Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.
      
      Job Responsibilities:
      • Provides and manages direct care to patients and families as part of Interdisciplinary Group (IDG), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
      • Coordinates the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
      • Educates patient, family, caregivers and other health professionals about disease process and decline, palliative interventions, care giving, dying process and safety practices.
      • Reports changes in the patient’s condition to appropriate members of the IDG or other health professionals.
      • Participates with the IDG to evaluate hospice referrals/admissions for level of care appropriateness.
      • Attends patient deaths; prepares body for transport; oversees disposal of medications.
      • Provides appropriate bereavement interventions to the family and caregiver in conjunction with psychosocial staff.
      • Presents concise and pertinent oral and written reports to IDG; respects and encourages input from all disciplines.
      • Communicates accurately and completely to physicians, staff members, patients, families, and supervisors; utilizes positive approaches when working with others.
      • Supervises patient care given by other nursing team members (i.e., LPNs, Hospice Aides, and contract nurses).
      • Performs other duties as assigned.
      
      Physical Demands for Post Offer/Pre-Placement (The demands described below are representative of those that must be met by an individual to perform the essential functions of the job, with or without reasonable accommodation.):
      
      While performing the duties of this job, the following abilities are required: see; hear; talk; walk; use hands to finger, handle or feel.
      
      Frequently required to: stand; sit; reach with hands/arms; lift; bend; balance.
      
      Occasionally required to: pull; push; stoop/crouch; kneel; climb stairs.

      This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.