Registered Nurse, Home Health Program Nurse Coordinator

About the role

Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking an RN, Home Health Program Nurse Coordinator to join our team.

Responsibilities

• Works under the supervision of the Director of Population Health and serves as the central coordinator for all home health referrals within the organization.
• Manages and monitors provider-initiated referrals to home health agencies to ensure timely initiation, appropriateness of services, and continuity of care.
• Acts as the primary liaison between medical providers, care teams, patients, and home health agencies and is critical in holding home health agencies accountable for delivering patient-centered, high-quality care aligned with clinical expectations and care plans.
• Works in collaboration with discharging facilities, and care management teams to facilitate appropriate referrals for GLFHC patients.
• Oversees referral processing, monitors the progress of home health services, and supports the certification and recertification process to ensure services remain medically necessary and aligned with the patient’s care plan.
• Plays an important role in supporting value-based care, by promoting appropriate use of home health services, improving care coordination, and helping patients safely receive effective care in the home setting, helping to improve health outcomes while reducing unnecessary utilization and expenses.
• Serves as a central access point for all referrals to home health providers, including evaluating medical necessities and appropriate utilization based on clinical acuity.
• Remains current in interpreting reimbursement guidelines to ensure patients’ services meet coverage criteria.
• Evaluates medical necessity and appropriateness of services based on clinical acuity.
• Reviews provider-initiated referral to ensure completeness, clinical appropriateness, including medical necessity that aligns with payor requirements.
• Serves as a subject matter expert for the integrated care team, including working with nursing to facilitate home health referrals.
• Coordinates with providers and care teams to obtain necessary documentation required for home health services.
• Maintains an organized tracking system for all active referrals and home health services.
• Serves as the primary point of contact for home health agencies, facilitating communication between agencies, providers, and care teams.
• Makes sure home health services are started on time and follow the prescribed care plan.
• Follows up with agencies regarding delays in care initiation, missed visits, or deviations from expected service plans.
• Escalates concerns regarding patient safety, services delays, or agency performance to appropriate providers or leadership.
• Collaborates with home health providers to develop relationships and conduct ongoing assessments of their clinical capability based on population served.
• Tracks all active home health referrals and services, maintaining an accurate registry to monitor patient progress and engagement.
• Follows up providers and home health agencies to completion of required documentation, orders and care plans.
• Reviews agency updates and documentation to determine whether services continue to meet medical necessity requirements.
• Collaborates with integrated care team including case managers, providers and Behavioral health staff, to ensure seamless coordination across all patient transitions.
• Participates in interdisciplinary care team meetings to provide input on patients receiving home health services.
• Educates patients and caregivers on the purpose of home health services and ensures they understand care plan.
• Identifies gaps in care and escalates concerns regarding patient safety, service delays, or non-compliance.
• Provides input on referral processes and performance of home health agencies for quality improvement purposes.
• Participates in ACO Home Health meetings to share updates, identify systemic challenges, and support population health strategies.
• Ensures compliance with HIPAA and all applicable federal, state and local regulations related to patient care and documentation.

Qualifications

• Minimum of seven years of clinical nursing experience, including a minimum of three years of experience working within a home health practice.
• Additional experience in utilization management, highly desirable.
• Proven ability to develop and maintain strong professional relationships with the Home Health community.
• Strong clinical assessment skills and understanding of home health eligibility criteria.
• Excellent organizational and communication skills.
• Experience working in community health center or primary care setting.
• Familiarity with local home health agencies and referrals workflow.
• Proficient in EHR systems and Microsoft Office.
• A valid driver’s license and access to reliable transportation.
• A vehicle is necessary to drive to and from each site as needed.

Benefits

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.