Collaborates and builds relationships of mutual respect with physicians, nurses, social workers, care managers and community partners through communication and education to facilitate smooth patient transitions. Regularly attends huddles, capture meetings, discharge rounds and outcome facilitation team meetings and acts as a resource regarding services that can be provided in the home. Communicates and collaborates with physicians, social workers and care managers on complex cases to ensure care needs can be met in the home setting. Upon referral, contacts patient to educate on agency service lines ensuring plan of care meets hospice eligibility and regulatory compliance. Collects and records medical, social, reimbursement information from hospital and post acute setting to initiate Advocate Aurora Health at Home services for hospice, infusion, enteral, pediatric, DME and RT services. Educates the patient, as well as, hospital and post acute providers, regarding patient financial coverage and responsibility for ordered services, and if available, provides the information prior to facility discharge. May follow Advocate Aurora Health at Home hospice patients readmitted to the hospital or post acute setting to evaluate the need for continued services. Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his/her age specific needs, and to provide the care needed as described in the department’s policies and procedures. Age-specific information is developed further in the departmental job standards. May participate in precepting new hire training and orientation. May be responsible for the admission to hospice services, including obtaining history/physical, implementing a care plan, managing signs and symptoms of terminal diagnosis to promote comfort at end of life Collaborates with Advocate Aurora Health at Home business development team and product line director to achieve admission growth and increase market share.
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Job Type
Full-time
Career Level
Mid Level
Number of Employees
11-50 employees