Responsible for collaborating with hospital and/or clinic caregivers as a resource regarding home care, palliative care, hospice, durable medical equipment (DME), respiratory therapy (RT), enteral and infusion services. Responsible for safely transitioning patients along the Aurora continuum of care by coordinating the admission process for Aurora At Home home care, palliative care, hospice, DME, RT, enteral and infusion referrals from within the hospital or clinic setting. Conducts patient visit(s) in the hospital to assist patients in understanding and accepting the transition to home care services. Develops relationships with hospital and clinic based physicians, nurses, social workers, case managers, and community partners by providing education regarding services that can be provided in the home.

Role

• Collaborates with both hospital and/or clinic caregivers as a resource regarding home care services and provides general education of services.
• Educates patients/families on home care, palliative care, and hospice services and is available to answer questions allowing patients to make an informed decision regarding their discharge plan for post-acute care.
• Regularly attends the outcome facilitation team meetings on the individual hospital units to provide input regarding services that could be provided in the home. Communicates with social workers or case managers on complex cases.
• Builds relationships of mutual respect with hospital and clinic based physicians, nurses, social workers, case managers, and community partners by providing good communication regarding patient transitions.
• Visits patients prior to discharge to ensure patients meet criteria for Centers for Medicare & Medicaid Services (CMS) regulations and has an understanding of provider orders for home care, palliative care, or hospice services upon patient selection of Aurora At Home as the provider of choice.
• Collects and records medical, social, and reimbursement data from the hospital and/or clinic record pertinent to initiating Aurora At Home home care, palliative, hospice, DME, RT, enteral, and infusion services.
• Follows Aurora At Home home care, palliative, and hospice patients readmitted to the hospital and evaluates their need for further services.
• Collaborates with hospital and/or clinic caregivers and patient/family regarding financial coverage of all Aurora At Home service lines, and if available, provides information prior to hospital discharge.

Scheduled Hours

Per Diem with weekend rotations

Licenses & Certifications

Registered Nurse license issued by the state in which the team member practices.

Degrees

Associate's Degree in Nursing.

Required Functional Experience

Typically requires 3 years of experience in clinical nursing including experience with discharge planning and/or case management.

Knowledge, Skills & Abilities

Excellent communication skills. Must be able to speak clearly and hear to communicate with people in person or over the telephone. Good organizational, analytical and problem solving skills. Proficiency in clinical skills with the ability to work under direction and make sound judgments. Demonstrated ability to educate clinical staff and the community. Demonstrated ability to work well with physicians and other professionals in a direct and positive manner. Ability to work in a team based environment and participate on multiple teams. Must have a thorough understanding of home care reimbursement to include Medicare, Medicaid and private insurance or ability to learn criteria. Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs. Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families.