Major Responsibilities:

Collaborates and builds relationships of mutual respect with physicians, nurses, social workers, care managers and community partners through communication and education to facilitate smooth patient transitions.Regularly attends huddles, capture meetings, discharge rounds and outcome facilitation team meetings and acts as a resource regarding services that can be provided in the home.  Communicates and collaborates with physicians, social workers and care managers on complex cases to ensure care needs can be met in the home setting.Upon referral, contacts patient to educate on agency service lines ensuring plan of care meets hospice eligibility and regulatory compliance.Collects and records medical, social, reimbursement information from hospital and post acute setting to initiate Advocate Aurora Health at Home services for hospice, infusion, enteral, pediatric, DME and RT services.Educates the patient, as well as, hospital and post acute providers, regarding patient financial coverage and responsibility for ordered services, and if available, provides the information prior to facility discharge.May follow Advocate Aurora Health at Home hospice patients readmitted to the hospital or post acute setting to evaluate the need for continued services.Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.  Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his/her age specific needs, and to provide the care needed as described in the department’s policies and procedures.  Age-specific information is developed further in the departmental job standards.May participate in precepting new hire training and orientation.May be responsible for the admission to hospice services, including obtaining history/physical, implementing a care plan, managing signs and symptoms of terminal diagnosis to promote comfort at end of lifeCollaborates with Advocate Aurora Health at Home business development team and product line director to achieve admission growth and increase market share.

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MINIMUM EDUCATION AND EXPERIENCE REQUIRED

License/Registration/Certification:  Registered Nurse

- A valid driver’s license issued by the Division of Motor Vehicles.

Issued by (Governing Body): State in which the team member practices

Level of Education:  Graduate from an accredited school of nursing, BSN preferred

Field of Study (if applicable):  Nursing

Years of Experience:  Typically requires 2 years of clinical nursing experience with discharge planning and/or care management.

Describe Type Experience:  Hospice experience preferred

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES (KSA)

Strong verbal and written communication skills. Can speak clearly and hear to interact in person, telephonically or virtually with both internal and external customers.Excellent organizational and critical thinking skills.Proficient knowledge of or ability to learn hospice regulations and reimbursement structure:  Medicare, Medicaid and Commercial PayersStrong technical ability.Able to think critically and assess the patient clinical condition to assist in the development of the post acute plan of care.May participate in training patient/family in use of equipment (ex. Enteral, infusion pumps)Familiarity with Epic preferred.May participate in processing referrals for hospice program.May include on call, weekend and holiday rotationSkilled in providing a positive patient experience, service recovery, and conflict resolution to promote collaboration among healthcare team mates, patient, and caregivers.

Physical Requirements and Working Conditions:

Responsible for the admission of patients and the coordination of care as needed Ability to travel and flexibility with hours and days to meet patient needs Ability to work two weekends per months as needed - minimum one weekend per monthIf position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.