Travels to non-System facilities. Has knowledge of each facility’s discharge planning process to accept and refer patients appropriate for skilled home care services. Under supervision, formulates and implements a Home Care Plan in conjunction with the physician, patient, patient’s family and discharge planner.
Job Responsibility
Responds to referrals in a timely manner and evaluates patients for appropriateness of skilled home care services.
Plans for the skilled home care needs of patient in a timely manner to ensure patient’s expeditious movement to the appropriate level of care.
Implements a comprehensive home care plan based on the in-depth assessment of the patient’s needs, including coordination of activities with family, informal supports and other community resources.
Maintains working knowledge of third-party reimbursement guidelines and regulation standards.
Functions as a home care service resource person.
Performs job functions in a fiscally responsible manner consistent with the mission and vision.
Assists with orienting new nursing personnel to department policies, procedures and practices.
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
