RN, Home Health, Team Lead (FT, Days)

About the position

To ensure coordination of care and services provided to all patients receiving home care services in the Home Health Program. Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines and services; use problem-solving and critical thinking skills to facilitate, coordinate, and execute effective, timely responses to clinical problems as they arise for patients and home care clinicians; and facilitate transitions across the continuum of healthcare settings for all home care patients.

Responsibilities

• Receives and evaluates appropriateness of the home health referral in collaboration with other team members.
• Ensures timely admission based on assessment.
• Assess clinical implications of services ordered, patient/caregiver ability to manage self-care, requirements for clinical monitoring, patient stability, and other factors that could impact safety and efficacy of admission care plan.
• Coordinate appropriate services and interventions by obtaining appropriate initial physician orders.
• Participate in the development and coordination of a comprehensive admission plan of care.
• Assure that appropriate supplies and equipment needed to provide initial services are available.
• Make recommendations to modify the plan of care to expedite a safe transition of care.
• Identify and communicate start of service to patient/caregiver and home care scheduling staff.
• Discuss and collaborate with referral source, home care team members, physician, discharge coordinator, and supervisor regarding complex discharges.
• Assist in identifying and coordinating alternative options to current care needs.
• Advocate for the patient and family to optimize utilization of resources.
• Coordinates referrals out to contract and non-contract providers for members that require home care services.
• Develop and maintain expert level of knowledge and skills related to agency policy and regulations.
• Provide telephone advice/problem-solving for patients/caregivers.
• Facilitates scheduling of follow up visits and procedures related to advice calls.
• Oversees the day to day staffing and patient schedules.
• Facilitates Care Conferences and coordinates care with Home Phlebotomy.
• Conducts Medication Reconciliation for Therapy only cases.
• Reviews and approves Home Health Aide Care Plans for Therapy only cases.
• Acts as Kaiser Permanente ambassador to provide member information to care facilities.
• Provide education to staff to expedite safe transitions of patients across care settings.
• Participates in orientation of staff to the department.
• Provides mentoring and coaching, and input into staff evaluations.
• Participates in quality and utilization management activities.
• Conducts patient home visits as required.
• Cross Home Health program coverage as needed.

Requirements

• Experience in home health care coordination.
• Strong problem-solving and critical thinking skills.
• Ability to collaborate with multidisciplinary teams.
• Knowledge of state and federal regulations related to home care services.
• Excellent communication and interpersonal skills.

Nice-to-haves

• Experience with electronic health records (EHR).
• Certification in home health care or related field.
• Bilingual skills.

Benefits

• 401k
• health_insurance
• dental_insurance
• vision_insurance
• paid_holidays
• tuition_reimbursement
• flexible_scheduling