RN Post-Acute Care Coordinator AdventHealth Home Health
All the benefits and perks you need for you and your family:
Commitment to whole-person care, giving you the opportunity to help heal people in mind body and spirit.
Fulfilling work with people who treat you like family.
Excellent benefits, market-driven wages and career development opportunities.
Recognized for the seventh year in a row as a recipient of the Gallup Great Workplace Award as part of the AdventHealth network.
Opportunities for advancement as we expand our network across the nation.
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.
The Post-Acute Care Coordinator (PAC) will function as the key patient advocate for coordination of post-acute care services within AdventHealth owned hospitals and Community based referrals including AH post-acute segments - home health, hospice, inpatient rehabilitation and skilled nursing facilities. This person will assist in assessing patients for post-acute care, coordinating the clinical transition to the appropriate post-acute setting and maintaining relationships with physicians, post-acute providers, therapists, patients and families. This person will be assigned a specific hospital or specialty and is responsible for collaboration with care management, the physicians and the clinicians to develop a discharge plan requiring post-acute services across CFD’s continuum of care.
The value you’ll bring to the team:
Responsible for conducting a systematic post-acute assessment of the physical, psychosocial and functional aspects of the patient and his/her family and their impact on the outcome potential to determine appropriateness for the Home Health care setting.
Inform and educate the patient and family about these post-acute settings, balancing the patient/family requests with what is required to provide safe, reliable, ongoing care for the patient.
Identify patient/family problems or needs ensuring communication to physician, care management and the clinical team.
Assist with coordination of home health care referrals within assigned hospital(s). Conducts Bedside assessment to determine appropriateness of HHC admission and completes medical necessity documentation, obtains insurance authorization, Educates patient/family regarding discharge plan and home care service expectations. Works closely with HHC Intake team to complete the pre-registration requirements for HHC admission.
Updates and communicates any DC plan changes to appropriate physician, discharge planner and intake customer service center.
Responsible for reviewing the discharge plan with Care Management and the clinical transition team from inpatient to post-acute care ensuring systematic handoff between care providers.
Participates in MDR, care conferences and coordination with Case Management.
Serve as a resource for the post-acute providers in the event issues arise post transition and prior to patient’s readmission ensuring patient’s care is triaged appropriately.
Strictly adhere to mandated federal, state, local regulatory and statutory requirements as well as AH policies and procedures for referral processing.
Act as a liaison and advocate for PAC patients readmitted to the hospital within 30 days.
Develop a presence in the medical community, confer with health care providers, promote educational opportunities as they present, and attend meetings as assigned.
Attends in-service training and mandatory company meetings
Perform other duties as assigned by management.
KNOWLEDGE AND SKILLS REQUIRED:
Post-Acute Care Conditions of Participations (COPs)
Demonstrated competency with required services of AH Post-Acute
Knowledge of post-acute (e.g., home health, skilled nursing facility, hospice, long-term acute care) regulations and CMS eligibility requirements
Demonstrates critical-thinking skills, analysis, and sound judgment in the evaluation process of patients and the patient’s support systems to address the physical, emotional, psychosocial and spiritual needs of the patient.
Represents AH post-acute services offering excellence in customer service and public relations skills.
Develops and builds relationships with referral source
Strong collaboration and communication skills with ability to actively resolve conflicts and act in the best interest of the patient
Proficiency in use of personal computer, copier, phone, facsimile machines
Strong organizational skills
Moderate – advanced computer skills
Strong customer service skills
The expertise and experiences you’ll need to succeed:
Associate degree in Nursing required
Two years of post-acute (e.g., home health and/or skilled nursing facility and/or hospice clinical experience) required
Experience working with the public and exceptional customer service skills required
Knowledge of medical terminology and the post-acute referral process required
A clear/active Florida Registered Nurse (RN) license required
Basic Life Support certification required
Valid Florida driver’s license, automobile insurance, safe driving record and reliable transportation required
More than two years post-acute (e.g., home health and/or skilled nursing facility and/or hospice clinical experience) experience (preferred)
Bachelor’s degree in business or medical-related field (preferred)
Successful sales or marketing experience (preferred)
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.