The Home Care Coordinator RN assists with care coordination of PACE participants; acts as the liaison for the interdisciplinary team between acute care facilities, congregate housing sites, the skilled nursing facilities, the contracted home care agency and various community settings where contracted services are provided; ensures appropriate paper work/communication is sent/received by contracted facilities as necessary to meet the ongoing care needs of participants.

Job Duties Specific to This Position:

• Evaluates appropriateness of new referrals to ensure in-home care needs can be met and that the potential client can be safely maintained in home environment; makes home visits on new referrals during the initial assessment process; during the intake and assessment process works with interdisciplinary team and participant/family to develop an appropriate plan of care.
• Follows participants in the hospital; calls the hospital discharge planner each business day or visits hospitalized participants as appropriate; reports immediately to provider if significant problem/change is noticed or reported; daily communicates with PACE CNY providers and hospitals/ hospital staff to assist in care coordination and to minimize hospital lengths of stay; works with interdisciplinary team and hospital discharge planner to coordinate a safe discharge and a smooth transition for participant from the hospital to home or to an alternate level of care; provides assistance and support to the participant and family during hospital stay; documents coordination of care in the medical record, may attend discharge meetings with the interdisciplinary team; coordinates need for a bed hold with the SNF, if necessary.
• Acts as a liaison with contracted home care agency to ensure home care agency is informed and has home care needs of participants as determined by the participant/caregiver and the PACE CNY team for new enrollees.
• Also acts as liaison for the interdisciplinary team and SNF staff and enriched living staff; may attend care planning meetings for SNF residents and participants who reside in an enriched living facility; may routinely visit/call contracted skilled nursing and enriched living facilities to review care needs, discuss participants’ status/progress updates and communicate/share information, i.e., family/participant/team goals, care plan updates, etc.; may also attend the reassessment meetings for long term care participants; may also visit contracted social day centers to observe participants in the environment, share information etc.
• Attends morning team meetings and provides status reports; shares pertinent information and communicates concerns/problems for team discussion and resolution as appropriate; completes assessments (SAMMs) every six months for participants residing in the SNF or EL facility; presents assessment to interdisciplinary team during team reassessment meeting for care planning purposes to ensure participant needs are met.
• Documents all communication with contracted agencies’ personnel, participants, families, etc. such as potential discharge date, status reports, planning interventions, etc. in a thoroughly accurate professional manner; maintains records in a confidential organized manner.
• Works in collaboration with the Director of Utilization Management/Information Systems for review of hospitalizations with extended length of stays, etc.
• Practices safety awareness, reports any possible safety/environment issues to supervisor, and adheres to safety policies and procedures.
• Demonstrates adherence to all compliance policies and procedures and the code of conduct. Is responsible for promoting, role modeling and fostering compliance in the workplace. Communicates expectations to employees regarding compliance oriented behavior.
• Performs responsibilities according to the highest quality standards.
• Demonstrates knowledge of PACE/D&TC Emergency Preparedness Plan and can verbalize their role during an event.

• Currently licensed as Registered Nurse in New York State.
• Two (2) years of experience in nursing, preferably in long term care or working with geriatric population as hospital discharge planner, etc.
• BSN is preferred.
• Current knowledge of best practice nursing standards and care.
• Ability to exercise good judgment and maintain confidentiality.
• Proven patient assessment skills.
• Proven organizational, time-management and interpersonal skills.
• Strong verbal and written communication skills.
• Self-directed and able to maintain schedule.
• Ability to operate under busy, stressful conditions.

An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.

Physical Requirements

Walking 30.00%

Sitting 30.00%

Standing 30.00%

Lifting 10.00% 25lbs

INDPRO

• Pay Range $77000 - $86500 / year
• Excellent medical, dental, prescription and vision insurance
• Disability coverage
• Tuition Reimbursement Program
• 401(k) Retirement/Pension Plans
• Discounted Gym Membership
• Generous Paid Time-Off Accrual
• Fun events for employees
• Convenient locations with free parking
• Employee Coaches - to help you achieve life goals
• Diaper Assistance Program
• Opportunity for career growth and movement within 19 sites!