Registered Nurse (RN) Patient Care Coordinator | Avera at Home Hospice and Home Health

McKennan Patient Care Coordinator

The McKennan Patient Care Coordinator (PCC) role offers nurses the opportunity to practice at the top of their license by coordinating complex care, connecting patients with needed services, and helping ensure smooth transitions across the healthcare continuum. PCCs build meaningful relationships with patients, families, providers, and community partners while making a direct impact on quality outcomes, patient experience, and care efficiency. This position is ideal for nurses who enjoy problem-solving, collaboration, and influencing care beyond the bedside while maintaining a strong focus on patient-centered care.

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview Accountable for the coordination of the patient's clinical services between hospital setting and the home setting. Promotes, educates and coordinates services when the patient is transferred from the hospital to care transitions, home healthcare or hospice services.

What You Will Do

• Serves as home care expert and resource to referral sources and/or agency staff regarding patient care, treatments and services that can be provided in the home/hospice setting including skilled and nonskilled services or other programs.
• Provides clinical assessment and assists referral sources with identification of appropriate services in the post-acute home care setting including education regarding admission criteria.
• Obtains physician orders, face to face, for home care/hospice services prior to each patient's admission to home care.
• Coordinates the home care/hospice plan as ordered by the physician.
• Clinical excellence and ability to proactively determine actual and potential complications in the home setting of care delivery for success of the patient.
• Documents each patient's home care plan and coordination activities according to standards established by Avera.
• Facilitates communication between entities and assigned hospital/agency staff, identifying and reporting processes in the system where communication and/or continuity of care can be improved.
• Maintains knowledge of Federal and State regulations as well as Agency policies and procedures.

Essential Qualifications The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

• Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire

Preferred Education, License/Certification, or Work Experience:

• 1-3 years home health/hospice related experience

Expectations and Standards

• Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera's values of compassion, hospitality, and stewardship.
• Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call View phone number on click.appcast.io or send an email to View email address on click.appcast.io.