Care Transition RN/LPN

Job Title

Provide comprehensive clinical assessment/screening of patients for appropriate levels of homecare.

Collects and documents detailed, pertinent information relative to a prospective patient's health care needs utilizing knowledge of clinical standards, procedures, medications, coding standards and community health care principles.

Utilizes critical thinking skills to implement pathway appropriate for patient care.

Obtain required clinical information that will enhance the admitting clinician's ability to conduct patient centered assessment in the home.

Obtain and process MD orders for all referrals. Expedite requests for services appropriately adhering to criteria for admissions using professional discretion and independent judgment.

Works collaboratively and professionally with other members of the health care team to ensure quality of services and patient safety.

Knowledge of diagnostic coding and implications for patient care system. Maintains knowledge of current agency services and criteria for admission.

Maintains current knowledge of agency policies, procedures, objectives and current documentation requirements to meet regulatory standards.

Communicates effectively and professionally on e-discharge systems. Efficiently and accurately enters data into the EMR.

Verifies, documents and reports specific payer eligibility and benefits for AR and Reimbursement.

Provides information and education regarding Agency services and programs to the public.

Triages telephonic requests for services appropriately.

Participates in Agency, clinical, QI, liaison, clinical reimbursement and case conferences activities as required.

Other duties as assigned.

Challenges current working practices; identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization's culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.

Successful passage of VNA pre-hire medication test.

RN currently licensed in Massachusetts (job code RNCT/RNCTPD) or LPN currently licensed in Massachusetts (job code 10611).

2 years' experience in healthcare, homecare experience preferred.

Experience with EMR and E-Discharge platforms preferred.

Ability to multi-task and manage multiple aspects of the referral process.