Healthcare Coordinator

The LPN Intake Coordinator/Educator is responsible for coordinating all new referrals made to the agency, ensuring that all new referrals meet the agency's policies and procedures as well as federal/state regulations and guidelines.

• Maintains working knowledge of current home health coverage guidelines, admission criteria, documentation requirements, coding guidelines, and care planning with case conference.
• Manages patient care accordingly, assessing the patient/caregiver willingness, ability, and barriers to learn patient care techniques and for achieving independence in care.
• Documents patient and family response to teaching, outlines aide care plan, and performs ongoing home health aide oversight.
• Revises aide care plan based on patient progress, evaluates home health aide care every 14 days or per state payer requirement, and participates in patient's plan of care and performance of skilled interventions at intervals defined by state.
• Conducts goal-oriented visits, ensures other nursing team members have information needed for continuity of care and continued progress, and provides patient/family teaching per POC.
• Assesses and documents response to teaching, advocates for the patient as required, and completes an accurate, initial comprehensive head-to-toe assessment.
• Completes OASIS and other assessments of patient and family to determine home care needs, obtains a history of current and previous illness(es), and uses health assessment data, input from agency team members, the physician, patient, and family to determine patient needs.
• Effectively manages patient and family expectations regarding agency services, outcomes/discharge goals, and ability to achieve independence in care, establishes appropriate primary and secondary diagnosis based on patient assessment and focus of home health care.
• Develops a care plan, incorporating appropriate skilled interventions, and necessary medical supplies/equipment and ancillary/specialty services, to achieve outcome/discharge goals, protects realistic home health visits by discipline and medical supplies required per planned interventions and discharge goals.
• Writes POC orders accordingly, regularly evaluates home health patient's progress, in collaboration with team members, and revises patient POC accordingly.
• Performs ongoing appropriate OASIS assessments and revises POC accordingly, identifies home health patient's discharge planning needs when developing the plan of care, identifies and implements community referrals prior to patient discharge, and determines patient readiness for discharge based on expected outcomes, goals, and coverage guidelines.
• Prepares clinical notes and other required documentation within the required timeframes, obtains/receives physician orders as required for treatment changes, and communicates new/changes orders to appropriate team members.
• Tracks all assigned cases, organizes schedule to ensure all patients' needs are met per their individual POC, meets agency productivity requirements, requests PTO in advance per agency protocol, and communicates with the Clinical Supervisor regarding the coordination of the plan of care, need for overflow, weekend, and after-hours nurse assignment.
• Ensures the availability of equipment/supplies and other necessary items to support care plans, uses equipment/supplies per plan of care and documents per agency policy, provides instruction for other team members, and provides updates for the primary physician when necessary and at least every sixty days.
• Facilitates ongoing care discussions and team case conference discussion of the patient goals, progression, needs for ongoing care, and revises goals and/or interventions to enhance patient progress toward discharge, plans and coordinates assignment of clinical staff to clients with input from the Home Health Director, Administration, and Physician as needed.
• Works cooperatively with other staff members in coordination of patient care services and disciplines, acts as liaison between clinical staff and community health care providers by communicating changes in patient status and care as potential referrals, including review of facility aware of Level of Care issues related to home care, and familiar with insurance reimbursements.
• Participates and assists in case conferences, in-services, and meetings as needed, works with personnel or other community agencies involved in the client's care as directed by the Home Health Services Director and with agency Team Coordinator/Staffing Specialists insuring appropriate staffing coverage for new referrals.
• Coordinates with agency RN Case Managers and clinical staff to assure efficient admission of new referrals, ensures effective and timely coordination of client home care services through the timely completion of required documentation and computer data entry for new intakes, as well as timely transfer of pertinent medical data to client's physician, therapists, and agency staff members.
• Maintains accurate and comprehensive client medical data throughout the intake process, notifies Branch Manager regarding proposed changes that may affect the intake process, investigates and takes appropriate actions on client/consumer complaints, and attends weekly Team Coordinator/Staffing Specialist meetings to insure consistent lines of communication regarding new intakes and existing cases needing staffing coverage.
• Supervises Team Coordinators to ensure effective handling of clients' schedules, new referral coordination assures agency intake processes meet applicable local, state, and federal licensing/regulatory requirements in addition to agency policies and procedures, directs the recertification process every sixty days by obtaining a roster of all patients with plan of treatments that are to be recertified and establishing completion of this process timely.
• Reviews medical records and updates treatment plan forms, audits medical records on each patient at the time of recertification, completes appropriate audits and forwards to Director of Patient Care Services, reviews recertification treatment plan summaries for transcribing or typing errors prior to Registered Nurse review and submission for physician's recertification audits with OASIS audits, quarterly chart audits, and adverse event audits.
• Assists Billing Coordinator with billing audits as necessary, communicates effectively to obtain patient information for ordered services, develops working relationship with hospital and insurance case managers to provide quality, compliant care, ensures all needed clinical information is provided to insurance companies to obtain authorization of services, and maintains client dashboard for pending referrals requiring authorizations into patient's electronic chart.
• Enters authorization information for patients into electronic system, participates in team conferences to discuss patient's needing authorization, maintains confidentiality of company and patient information, provides proper notification and/or advance notice of absence or tardiness without abuse.
• Participates in personal, professional growth and development, maintains current licensure, independently seeks learning opportunities, participates and contributes to QAPI program, attends all in-services training sessions and programs required by agency.