Registered Nurse Intake Coordinator - Hospital at Home - Per Diem

Position Details

Screens potential new enrollees and evaluates and coordinates new enrollees to the appropriate Case Management Program. Assists Case Team Staff with outreach activities to support care initiatives for members throughout the care continuum.

• Works with leadership to create appropriate support materials regarding program purpose, goals and objectives and deliverables.
• Meets with physicians across both Geisinger and the community to share details on the program.
• Identifies patients for recruitment and reviews with the appropriate primary and specialty care providers.
• Completes patient outreach and formal evaluation of all potential enrollees for the program to determine participant needs and eligibility for enrollment.
• Completes thorough review of all medical records including laboratory and radiology reports.
• Discusses care needs with primary or specialty care providers as needed.
• Interviews patient and family for in-home care needs as well as other behavioral or social gaps.
• Visits patients and families in their homes, at the hospital or nursing home for recruitment into program.
• Segments patients to the appropriate care team including home based medical team, community palliative care team or mobile integrated health team.
• Provides formal handoff to the appropriate care team.
• Schedules first visit with care team.
• Establishes and maintains an effective working relationship with County Area Agency on Aging and County Assistance Office delegates to provide a streamlined enrollment application process for Community Resources.
• Communicates with referral sources including physician offices, hospital discharge planning, and other community agencies for follow up in completion of the intake record.
• Provides follow up communication and correspondence to complete the enrollment process.
• Supports triage phone service taking acute care calls from patients and families or other care providers.
• Effectively assess acute care need.
• Manages gaps if able immediately.
• Identifies resources needed to respond to acute care need.
• Activates the correct care team or 9 as indicated by acuity of acute care need.
• Participates in weekly IDT meetings being prepared to share acute care activities for appropriate patients.
• Identified patterns to help the care team in Plan of Care adjustments.
• Maintains documentation of enrollment process, including prospective participants within designed software programs as necessary to complete mandatory state statistical reporting functions.
• Assists Administrative staff with completion of reporting requirements.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Education

Graduate from Specialty Training Program-Nursing (Required)

Experience

Minimum of 1 year-Nursing (Required)

Certification(s) and License(s)

Licensed Registered Nurse (Pennsylvania) - RN_State of PennsylvaniaRN_State of Pennsylvania

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence.

LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.

Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all.

We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.