Job Description

POSITION SUMMARY : The Patient Care Coordinator (Nursing) is accountable for the administrative and clinical coordination and management of multidisciplinary care teams. The coordinator ensures that patient care's administrative and clinical aspects are consistently maintained at the highest home health standards, continuity of care, and service delivery are most efficient. 

ESSENTIAL DUTIES & RESPONSIBILITIES:

Care Coordination and Scheduling

• Assist in managing patient care and ensuring quality service and satisfaction. 

• Works in partnership with administrative and clinical personnel throughout the agency. 

• Monitor the work of schedulers, field clinicians, and other administrative office personnel and assist in working more effectively.

• Manage intake and referral processes, including insurance verification and authorization.

• Coordinates schedules for in-home visits by nurses, therapists, and other care providers.

• Maintain accurate and up-to-date records in the EHR.

Patient and Family Communication

• Act as the primary point of contact for patients and families regarding care plans and service updates.

• Communicate with empathy and clarity, keeping family members informed about care plans, schedule changes, or new physician orders.

• Address the concerns/complaints of the patient, caregiver, client, provider, and other stakeholders, resolving the issues and escalating as needed.

Interdisciplinary Team Collaboration

• Facilitate and participate in multidisciplinary case conference meetings with administrative and clinical personnel to coordinate the delivery of patient care.

Care Plan Management

• Administratively partner with admitting clinician and other administrative personnel to facilitate the completion of the plan of care (485) and other administrative paperwork for compliance.

• Maintain and update individualized care plans for each patient.

• Monitors patients’ progress and ensures timely reassessment and care plan updates.

• Coordinate with the clinical team to adjust care plans or visit frequency as necessary.

• Ensure services are delivered in accordance with the physician's orders and agency policy.

Patient Follow-Up

• Conduct regular follow-ups with field clinicians through supervisory home visits to check patients' well-being and confirm that the care instructions are being followed.

• Conduct regular follow-up through phone calls to identify any new needs and service satisfaction.

Documentation and Records

• Performs data entry, record keeping, correspondence, computer composition, technical drafting, and office work.

• Answers the phone, answers routine (non-clinical) administrative and clinical questions from patients, physicians, and providers reading information from an electronic health record (EHR).

• Maintains confidentiality and safety of patient clinical records.

• Maintains administrative compliance with the submission of all clinical orders, authorizations, visits, and other documents required by federal and state regulations.

Regulatory Compliance

• Assist the management team in administering, planning, and facilitating in-services. 

• Assist the management in compliance with the required documents required by the state and federal regulations.

• Assist the management team in compliance with the Medicare/Medicaid requirements and HIPAA privacy rules.

• Comply with accepted professional standards and principles.

• Verify that the care delivery matches the physician's orders and authorized frequencies.

• Assist in managing compliance with the OASIS assessment transmittal to the federal government.

• Maintain compliance with Medicare, Medicaid, and other payor requirements.

Quality Assurance

• Participate in quality improvements and compliance activities.

• Conduct audits and review patient charts for completeness.

• Work with the management team to develop better processes for care coordination.

• Assist in identifying problems with performance and developing solutions to those problems.

• Provide input on improving patient satisfaction and outcomes based on feedback and observation.

• Initiate informal measures to correct performance issues for formal disciplinary actions to the management team.

• Recommend training needs to improve performance of the administrative and clinical team.

• Perform other administrative & clinical duties and activities as delegated.

• Position Overview statements are only meant to summarize the major duties and responsibilities performed by the incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

EDUCATION/ LICENSURE REQUIREMENTS:

• Currently licensed as an Registered Nurse (RN) in California) 
• Graduate of a school of professional nursing approved by the Board of Registered Nursing (BRN) or accredited by the National League for Nursing Accrediting Commission (NLNAC)
• Maintains a current BLS (basic life support) for Healthcare Providers CPR / AED (cardio-pulmonary resuscitation / automated external defibrillator) certification.

QUALIFICATIONS & SKILLS:

• Preferred: Administrative experience in a pre-acute, acute, or post-acute setting leading and executing administrative functions.

• Preferred: clinical experience in a pre-acute, acute, or post-acute setting leading and executing administrative functions.

• Required: Data entry, answering telephones, filing administrative & clinical records.

• Preferred: Two (2) years’ of professional nursing experience within the last five (5) years, in either a home health agency, primary care clinic or healthcare facility strongly desired. 

• Preferred: One (1) year of recent Home Health experience.

• Preferred: Management experience.

• Preferred: Sufficient background knowledge and expertise in administrative leadership, planning, and execution in support of clinical decision-making for the patient population assigned to him or her in the home health agency to meet the needs of his or her patients and to contribute to quality management review and evaluation.

• Sufficient computer skills to operate an Electronic Medical Record system. 

• Sufficient knowledge of Medicare regulations is necessary to be knowledgeable and able to perform an OASIS assessment.

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