Nursing Patient Care Coordinator RN

POSITION SUMMARY

The Patient Care Coordinator (Nursing) is accountable for the administrative and clinical coordination and management of multidisciplinary care teams. The coordinator ensures that patient care's administrative and clinical aspects are consistently maintained at the highest home health standards, continuity of care, and service delivery are most efficient.

Acting as the administrative liaison between the agency, patients, caregivers, payers, and providers.

• Assist in managing patient care and ensuring quality service and satisfaction.
• Works in partnership with administrative and clinical personnel throughout the agency.
• Monitor the work of schedulers, field clinicians, and other administrative office personnel and assist in working more effectively.
• Manage intake and referral processes, including insurance verification and authorization.
• Coordinates schedules for in-home visits by nurses, therapists, and other care providers.
• Maintain accurate and up-to-date records in the EHR.

• Act as the primary point of contact for patients and families regarding care plans and service updates.
• Communicate with empathy and clarity, keeping family members informed about care plans, schedule changes, or new physician orders.
• Address the concerns/complaints of the patient, caregiver, client, provider, and other stakeholders, resolving the issues and escalating as needed.

• Facilitate and participate in multidisciplinary case conference meetings with administrative and clinical personnel to coordinate the delivery of patient care.

• Administratively partner with admitting clinician and other administrative personnel to facilitate the completion of the plan of care (485) and other administrative paperwork for compliance.
• Maintain and update individualized care plans for each patient.
• Monitors patients’ progress and ensures timely reassessment and care plan updates.
• Coordinate with the clinical team to adjust care plans or visit frequency as necessary.
• Ensure services are delivered in accordance with the physician's orders and agency policy.

• Conduct regular follow-ups with field clinicians through supervisory home visits to check patients' well-being and confirm that the care instructions are being followed.
• Conduct regular follow-up through phone calls to identify any new needs and service satisfaction.

• Performs data entry, record keeping, correspondence, computer composition, technical drafting, and office work.
• Answers the phone, answers routine (non-clinical) administrative and clinical questions from patients, physicians, and providers reading information from an electronic health record (EHR).
• Maintains confidentiality and safety of patient clinical records.
• Maintains administrative compliance with the submission of all clinical orders, authorizations, visits, and other documents required by federal and state regulations.

• Assist the management team in administering, planning, and facilitating in-services.
• Assist the management in compliance with the required documents required by the state and federal regulations.
• Assist the management team in compliance with the Medicare/Medicaid requirements and HIPAA privacy rules.
• Comply with accepted professional standards and principles.
• Verify that the care delivery matches the physician's orders and authorized frequencies.
• Assist in managing compliance with the OASIS assessment transmittal to the federal government.
• Maintain compliance with Medicare, Medicaid, and other payor requirements.

• Participate in quality improvements and compliance activities.
• Conduct audits and review patient charts for completeness.
• Work with the management team to develop better processes for care coordination.
• Assist in identifying problems with performance and developing solutions to those problems.
• Provide input on improving patient satisfaction and outcomes based on feedback and observation.
• Initiate informal measures to correct performance issues for formal disciplinary…