RN, Care Coordinator SNF at Home

Baystate Health•Springfield, MA

About The Position

SNF@Home Coordinator The SNF@Home coordinator is a grant-funded position responsible and accountable for the planning, organizing, directing, and coordination of clinical and administrative performance of the SNF@Home program. Collaborates with hospital case management, compliance, legal, finance, providers, and the entire SNF@Home team to ensure patient needs are met within the guidelines of the SNF@Home grant. The successful candidate will possess strong clinical skills, supervisory skills, and the capacity to work well autonomously and within a team. This position is integral to the successful enrollment of patients into the SNF@Home program and will be a key contributor to the success of the grant.

Requirements

MA RN License
Associates Degree with 3 years of home care, clinical experience, or hospital case management experience
Valid Drivers License and DMV check required
Strong critical thinking skills, the ability to work autonomously, and experience leading a group are strongly preferred.

Responsibilities

Takes the lead role in screening/assessing patients for the program based on predetermined criteria for study enrollment.
Provides ongoing education and insight to others regarding preferred study participants
Works in partnership with the Research and BHH clinical management teams to communicate and collaborate on all potential participants meeting study criteria.
Functions as the key driver in approaching all potential patients to educate patients & families on all program aspects, working closely with Research staff to communicate and collaborate on the enrollment process
Requires both strong clinical and case management knowledge to successfully navigate the screening and assessment process in enrolling successful patients
Works closely with staff & leadership from BMC Case Management to identify study patients, follow the progression of care leading to hospital discharge, and ensure that dual discharge plans (SNF & HOME) are in place until randomization of study is completed.
Takes a lead role in coordinating care between BMC, Baystate Home Health, and all applicable 3rd party vendors associated with the program and patient's discharge needs.
Coordinates elevated care with MIH provider, SNF@provider, Hospital, or SNF as needed.
Makes home visits to patients as required.
Takes a lead role in daily clinical and IDT rounds with SNF@Home providers and the clinical team.
Provides clinical updates and communications and ensures care is progressing at home as planned.
Follows up on needs after daily updates.
Excels in communication and organization skills.
Keeps track of all components of care with each study participant, escalating issues/concerns promptly and efficiently
Strong clinical knowledge in screening potential patients is required, including experience in acute hospital care, SNF level of care criteria, and home health level of care criteria.
Coordinates clinical practice and deployment of resources, supplies, and DME to patient's home prior to discharge from the hospital in collaboration with the hospital case management team
Coordinate with Baystate Home Health leadership and oversee scheduling of all disciplines, including remote patient monitoring and provider visits.
Follows up with any needed services for patients
I n coordination with Baystate Home Health leadership, monitors supply usage and ordering to ensure fiscal responsibility within the confines of the grant
I n coordination with Baystate Home Health Finance, manages SNF@Home patient tracking report and works in collaboration with BHH team and third-party vendors to ensure proper billing of services.