Come make a difference with a growing organization that is helping to shape the future of healthcare! CareCentrix is committed to making the home the center of patient care. As a Nurse Coach you will utilize clinical expertise to manage assigned Post-Acute Care patients’ transition from acute care setting to the home setting through telephonic outreach to provide education, coaching and care coordination to accomplish the goals of the Post-Acute Care Program.
Post-Acute Care (PAC) Program is an end-to-end post-acute offering that manages up to 90-day episodes of care, beginning prior to the patient's discharge from the hospital, or for elective surgical cases, outreach begins prior to hospitalization. The program optimizes our home-based network, identifies the likely best site-of-care for the patient, manages length of stay (LOS) if a Skilled Nursing Facility (SNF) is appropriate, and reduces hospital readmissions. Our program also coordinates all of the services required for a patient to transition to their home faster and safer, via our network of home health, durable medical equipment and home infusion providers, all of whom are supported by our CareCentrix care coordination team.
• Using clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the Post-Acute Care Program and specific plan payer criteria.
• Care coordination and facilitation with hospital discharge planners, case managers and hospitalist to obtain Post-Acute Care orders for engagement.
• Manages the transition of assigned Post-Acute Care patients from acute care setting to the home setting utilizing telephonic outreach and teaching methods combined with facilitating in home health care services to accomplish the goals of the Post-Acute Care Program. Case management combined with facilitating home health nursing services.
• Initiates outbound calls to Post-Acute Care patients, hospitals, discharge planners, physicians, and home health agency nurses providing education regarding the benefits of Post-Acute Care.
• Engages Post-Acute Care patient in the program and administers initial assessments, progress surveys and discharges surveys utilizing clinical expertise and judgment. Obtains and reviews home health agency program documentation, medication reconciliations and surveys.
• Documents all interactions, guidance and interventions in CareCentrix applications ensuring documentation guidelines are maintained.
• Facilitates obtaining appropriate home health physician orders for the home care services.
• Acts as a clinical resource for unlicensed Post-Acute Care Coordinators, providing clinical expertise and helping to clarify referral source directives. Receives/responds to requests from unlicensed staff regarding scripted clinical questions and issues.
• Makes on-going reauthorization decisions for Post-Acute Care patients and issues service reauthorizations for the home care provider based on medical necessity and payer benefit guidelines.
• Contacts referral sources to advise them of referral status. Relays referral status and updates to the assigned health plan case managers.
• Communicates customer service/provider issues to supervisor for logging and resolution.
• Participates in and contributes to ongoing quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested.
• Assists team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
• Participates in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
• Typical work schedule is Monday thru Friday 8am to 6pm. Based on business needs, evening and weekend coverage may be needed at times.
CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.