RN Home Health/Hospice Coordinator

Duke Careers • Durham, NC

4d • Onsite

About The Position

The Care Coordinator is a dynamic, fast-paced role focused on coordinating home health, hospice, and infusion services for patients at Duke University Hospital (with opportunity to occasionally work at Duke Regional Hospital). This position assesses patients’ home care needs, provides education to patients and caregivers, and helps ensure they are prepared to safely manage care at home, including hospice, home health, and infusion therapies. Working closely with interdisciplinary teams, referral sources, and community partners, the Coordinator plays a key role in creating seamless, high-quality transitions from hospital to home.

Requirements

• BSN required.
• Current RN licensure in the state of North Carolina, or compact licensure in participating state is required.
• BLS required, but if not current may be renewed during orientation.
• Three years of nursing experience are required.

Responsibilities

• Utilize comprehensive assessment skills to determine a patient’s appropriateness for home care, initiate the appropriate home program referral, and provide patient/family education related to the initiation of home care services.
• During patient/family education, identify any barriers or concerns related to home care by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Communicate the identified concerns to the Case Manager or physician team to develop a comprehensive discharge plan.
• Provide ongoing daily assessment and monitoring of patient referrals until discharge to ensure all patients have the appropriate services, including ongoing home support. Coordinate with the hospital Case Manager to request additional services/orders.
• Maintain effective communication with the health care team related to assessment findings, additional discharge planning needs, and during patient/family education.
• Electronically document all activity in Maestro and CareTend and other documentation systems relevant to the position.
• Meet with referral sources regularly to identify gaps in care, patient population needs, opportunities for referral process improvement, and ongoing identification of additional patient/staff educational opportunities.
• Maintain a working knowledge of specific insurance benefits, reimbursement guidelines, and maintain an understanding of their impact on the delivery of home health, hospice, and infusion services.
• Maintain a working knowledge of applicable federal and state regulatory guidelines related to home care services.
• Maintain a current knowledge base of the comprehensive services, products, and supplies available through DHCH.
• Work with DHCH referral center, finance, and the appropriate home program to accurately complete and obtain any additional required documentation to facilitate the prevention of an insurance denial for services.
• Develop and maintain a positive relationship with internal and external customers.
• Job responsibilities may include site-specific duties, weekend/holiday or after-hours coverage as designated at each entity.
• Perform other related duties incidental to the work described herein.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level