Registered Nurse RN Coordinator Hospital at Home

All the benefits and perks you need for you and your family :

• Benefits from Day One
• Paid Days Off from Day One
• Career Development

Our promise to you :

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit.

AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ.

Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule : Full Time

Shift : M-F 7 : 30-4 : 50 rotating weekends

Location : 200 N Lakemont Ave, Winter Park, FL 32792

The role you’ll contribute :

The RN Coordinator for AdventHealth Hospital at Home (AHHaH) will ensure safe and quality hospital level clinical care and the provisions of excellent consumer experience is provided to AdventHealth Hospital at Home patients.

The RN Coordinator in collaboration with the patient / family, social workers, nurses, providers, and the interdisciplinary team, identifies patients meeting the inclusion criteria of an AdventHealth Hospital at Home patient.

This position coordinates all aspects of patient care transfer from the acute care hospital to the patient’s home / residence while maintaining acute care level care, excellent patient satisfaction, and patient safety.

Communicates daily with the interdisciplinary team during daily multidisciplinary rounds, responds to plan of care changes by coordinating in home resources, DME or supplies.

The RN Coordinator is responsible for patient evaluations of post- AHHaH needs; development of a transition of care plans and the implementation of post-acute care plans discharge.

The RN Coordinator will serve as an educational resource for patients / family members, providers, clinical staff at acute care and patient’s homes.

The RN Coordinator adheres to departmental and system goals, objectives, policies and procedures, CMS CoP for discharge planning / care coordination and ensures quality patient care and regulatory compliance.

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you’ll bring to the team :

• Demonstrates, through behavior, AdventHealth’s core values, Integrity, Compassion, Balance, Community Well-Being, Quality and Service Excellence.
• Reviews patient census and identifies patients meeting the AdventHealth Hospital at Home (AH HaH) inclusions criteria and review selected patients with providers and acute care / emergency department clinical team.
• Assist provider(s) in obtaining informed consent into the AHHaH program.
• Facilitates collaborative management of patient care across the continuum, intervening to ensure timely, safe, and efficient care delivery.
• Reviews necessary patient information including labs, medications, History and Physical, Therapy notes, ED notes, test results and progress notes to ensure at home services are coordinated.
• Completes initial AHHaH assessment prior to transfer to the program. Conducts daily virtual check-ins with the patient to monitor the patient progress and to address any care needs or concerns.
• Incorporates the patient / family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
• Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
• Assists with End-of-Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
• Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
• Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
• Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
• Ensures reassessment of discharge needs provided anytime a patient’s condition changes and / or the circumstances impacting the provision of post-hospital care changes.
• Educates patients and family about post-acute care and services available to the patient including, but not limited to the following : Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations.
• Ensures patient notifications are provided and documented in a timely manner for compliance : Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
• Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
• Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
• Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
• Participates in department and hospital Performance Improvement activities.
• Provides necessary patient care coverage and assistance with other duties as assigned when needed.
• Promotes individual professional growth and development by meeting requirements for mandatory / continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
• RN Coordinator may act as a Clinical Charge nurse when assigned by the AHHaH Nurse Manager.
14 days ago