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Position is located in Carilion Roanoke Memorial Hospital. This position works under the Home Health/Hospice Department and involves carefully assessment and coordination of discharge needs- arranging follow up care etc. Sign on bonus eligible.

Maintains working knowledge of referral requirements for both home health and hospice and keeps abreast of all regulatory changes/updates impacting referral acceptance and coverage criteria.
Collaborates with pre-authorization as appropriate to ensure patients are in network for coverage.
Collaborates with Central Intake/Central Scheduling to ensure discharge needs can be met timely.
Utilizes Patient Driven Groupings Model (PDGM) diagnosis modalities within the electronic record to ensure regulatory compliance with referring diagnosis for home health referrals.
Cross-references chart documents to ensure required elements are present and meet home health face-to-face requirements at the time of referral.
Masters the use of the electronic medical record as well as referral handoff software.
Aids in the delivery of regulatory letters and patient notices related to insurance coverage/non-coverage using support staff as appropriate.
Ensures documentation accurately reflects the patients condition co-morbidities treatment and procedures that support the most appropriate admission status and HHRG assignment.
Communicates with patients/families to ensure understanding financial implications of discharge plans.
Facilitates an interdisciplinary approach to patient care- evaluating needed disciplines to achieve goals and ensuring orders are obtained accordingly.
Serves as subject matter experts for interdisciplinary review ad hoc.
Maintains effective communication with Case Management Home Care and Hospice staff and providers as indicated.
Confirms community based primary care provider accepting the patient post discharge.
Actively pursues communication skills needed to manage sensitive end of life discussions.
Aids in transitioning hospice patients to General Inpatient status as the need arises.
Actively engages with inpatient staff serving as a subject matter expert for both home health and hospice needs referral eligibility and services provided.
Diligently reviews referrals for any safety concerns collaborating with leaders/resources as necessary to develop a sound plan for referral acceptance.
Serves as a liaison/resource to inpatient departments for home care and hospice needs.
Provides feedback to the health care team verbally and via chart entries regarding discharge planning . Manages changes to the plan as necessary.
Advocates for the patient and family throughout the entire episode of care.
Participates in departmental and system performance improvement initiatives.
Contributes to Carilion Clinics performance improvement activities engaging with predictive analytic software- sharing readmission risk scores.
Maintains individual caseload of patients while ensuring flexibility to cross cover for co-worker absence ensuring complete assessment of referral/discharge needs.

What We Require:

Education: Registered Nurse. Bachelors degree required. 5 years of RN experience in a hospital setting may be considered in lieu of a bachelors degree.

Experience: Three years of recent experience in a clinical health care setting with responsibilities reflecting direct management of patient care including planning coordination and delivery of needed services such as education psychosocial support discharge planning and utilization management. Supervisory or leadership experience is preferred.

Licensure certification and/or registration: Current licensure in Virginia as a Registered Nurse.

Life Support: AHA BLS- HCP required within 6 months of hire.

Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: satisfactory completion of orientation; positive interpersonal oral communication skills; effective written communication skills; integrity; innovation; team player; courteous; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability; willingness to work as an integral member of a multi-skilled team. Also demonstrate knowledge and competency in; computer literacy; community and system resources; effective interpersonal relations; assertiveness; flexibility; perseverance; diplomacy and negotiation.

This job description is only meant to be a representative summary of the major responsibilities and accountabilities performed by the incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

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For more information contact the HR Service Center at 1-.

Carilion Clinic is an Equal Opportunity Employer: We provide equal employment opportunities to all employees and applicants without regard to race color religion sex national origin age (40 or older) disability genetic information or veterans status. Carilion is a Drug-Free Workplace. For more information or for individuals with disabilities needing special assistance with our online application process contact Carilion HR Service Center at 8:00 a.m. to 4:30 p.m. Monday through Friday.

For more information on E-Verify: Pay and Well-beingat Carilion Clinic

Carilion understands the importance of prioritizing your well-being to help you develop and thrive. Thats why we offer a well-rounded benefits package and many perks and well-being resources to help you live a happy healthy life at work and when youre away.

When you make your tomorrow with us well enhance your potential to realize the best in are benefits available to you when you join Carilion:

• Comprehensive Medical Dental & Vision Benefits
• Employer Funded Pension Plan vested after five years (Voluntary 403B)
• Paid Time Off (accrued from day one)
• Onsite fitness studios and discounts to our Carilion Wellness centers
• Access to our health and wellness app Virgin Pulse
• Discounts on childcare
• Continued education and training