Job Summary:

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.

Essential Responsibilities:



+ Referral and Admissions to Home Care: Receives and evaluates appropriateness of the home health referral in collaboration with other team members (care team members, supervisor, scheduler, care (discharge) coordinators, long-term care team, expanded care, physicians, clinic social workers, and others as needed). Ensures timely admission based on assessment. Ass...