Registered Nurse (RN) Patient Care Coordinator | Avera at Home Hospice and Home Health

Avera•Sioux Falls, SD

7d•Remote

About The Position

Accountable for the coordination of the patient's clinical services between hospital setting and the home setting. Promotes, educates and coordinates services when the patient is transferred from the hospital to care transitions, home healthcare or hospice services.

Requirements

Registered Nurse (RN) - Board of Nursing
An active license in the state of practice Upon Hire
The individual must be able to work the hours specified.
Visual acuity adequate to perform position duties
Ability to communicate effectively with others
Ability to hear, understand and distinguish speech and other sounds.

Nice To Haves

1-3 years home health/hospice related experience

Responsibilities

Serves as home care expert and resource to referral sources and/or agency staff regarding patient care, treatments and services that can be provided in the home/hospice setting including skilled and nonskilled services or other programs.
Provides clinical assessment and assists referral sources with identification of appropriate services in the post-acute home care setting including education regarding admission criteria.
Obtains physician orders, face to face, for home care/hospice services prior to each patient’s admission to home care.
Coordinates the home care/hospice plan as ordered by the physician.
Clinical excellence and ability to proactively determine actual and potential complications in the home setting of care delivery for success of the patient.
Documents each patient’s home care plan and coordination activities according to standards established by Avera.
Facilitates communication between entities and assigned hospital/agency staff, identifying and reporting processes in the system where communication and/or continuity of care can be improved.
Maintains knowledge of Federal and State regulations as well as Agency policies and procedures.