HomeCare Navigator (Referral, Intake, Care Transition)

Responsibilities

Timely and effective response to homecare referrals.

Assess and align the appropriate level of care, services and programs with the goals of care for the patient based on the information received from the referral source, field HomeCare Transitional Coordinator and/or patient Transitional assessment may occur through chart review and patient interview either in person or virtually/telephonic.

Serves as a bridge between the healthcare team and the patient and/or caregivers.

Self-directed, with a spirit of team support and success, curiosity and ownership, flexibility and a consistent demonstration of H3W Leadership behavior and modeling.

Maintains accuracy of patient records, charts and documents to support sound medical practice.

Monitors timeliness and appropriateness of system hospital referrals, partnering with Intake/Insurance, Care Transition Nurse, and Regional Team to support transition to HHCAH and ensuring appropriate discipline visits.

Initial assessment of patient home care qualifications including but not limited to authorization of services, identification of physicians, appropriate home care services.

Identify and assure home care transitional needs are in place prior to patient admission to home care services including but not limited to procedural supplies (foley, wound, pleural catheter, etc), Community MD verification, community resource needs and appropriate services ordered.

Prepares and maintains accurate patient records, charts and documents to support sound medical practice.

Adheres to the practice of confidentiality (HIPAA and other state/federal regulations) regarding patients, families, staff and the Agency.

Develops effective relationships with multiple stakeholders including but not limited to System Case Management teams, Insurance/Intake Transition Support and Care Transition Nurses to enhance patient transition and assignment.

Consistently communicates with HHCAH management to make sure all issues and problems are seamlessly handled so that both the patient and the referring source are satisfied with the results and process.

Promotes a cooperative, cohesive group process dedicated to provision of quality patient care with achievement of best possible patient outcomes; collaborates with multiple system partners across regions.

Participates in Performance Improvement activities within the Agency.

Responsible for the quality, transition, financial and patient satisfaction outcomes.

Identifies patient home care qualifications including but not limited to authorization of services, identification of physicians, appropriate home care assignment based on set algorhytms.

Maintains utilization statistics in line with national best practice benchmarks and optimizes clinical outcome scores as evidenced by Home Health Compare and its equivalents.

Supports Daily transitional huddles, participates in Lean Daily Management, and daily and weekly case conferences with the transitional teams as needed.

Qualifications

Associates Degree required. Bachelor's degree preferred.

Minimum of 1 year preferably in acute care or homecare setting.

Familiarization with Epic EMR in home care setting preferred.