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RN - Registered Nurse Intake Coordinator Hospital at Home

Job Summary

As one of the Top 8 Most Innovative Healthcare Systems in Becker’s Hospital Review, we’re working to create a national model for improving health. Today, we’re focused on bringing our region services that improve every facet of life to drive total health, inside and out. Through professional growth, quality improvement, and interdisciplinary collaboration, we’ve built an innovative culture that allows nurses to grow their skillsets, develop their practice, and leverage their years of experience to build a rewarding, lasting career with impact.

Job Duties

The RN Intake Coordinator screens potential new enrollees and evaluates and coordinates new enrollees to the appropriate Case Management Program. Assists Case Team Staff with outreach activities to support care initiatives for members throughout the care continuum.

This position is full-time, 40 hours weekly, 4 days per week - giving you more work-life balance and a weekday off!

The schedule is days, (4) 10-hour shifts per week, includes every other weekend, and every other holiday rotation. This role is office based and located out of Geisinger's Hughes Center in Danville, PA.

At least one year of RN work experience is required. Previous RN Case Manager experience is preferred

• Works with leadership to create appropriate support materials regarding program purpose, goals and objectives and deliverables.
• Meets with physicians across both Geisinger and the community to share details on the program.
• Identifies patients for recruitment and reviews with the appropriate primary and specialty care providers.
• Completes patient outreach and formal evaluation of all potential enrollees for the program to determine participant needs and eligibility for enrollment.
• Completes thorough review of all medical records including laboratory and radiology reports.
• Discusses care needs with primary or specialty care providers as needed.
• Interviews patient and family for in-home care needs as well as other behavioral or social gaps.
• Visits patients and families in their homes, at the hospital or nursing home for recruitment into program.
• Segments patients to the appropriate care team including home based medical team, community palliative care team or mobile integrated health team.
• Provides formal handoff to the appropriate care team.
• Schedules first visit with care team.
• Establishes and maintains an effective working relationship with County Area Agency on Aging and County Assistance Office delegates to provide a streamlined enrollment application process for Community Resources.
• Communicates with referral sources including physician offices, hospital discharge planning, and other community agencies for follow up in completion of the intake record.
• Provides follow up communication and correspondence to complete the enrollment process.
• Supports triage phone service taking acute care calls from patients and families or other care providers.
• Effectively assess acute care need.
• Manages gaps if able immediately.
• Identifies resources needed to respond to acute care need.
• Activates the correct care team or 9 as indicated by acuity of acute care need.
• Participates in weekly IDT meetings being prepared to share acute care activities for appropriate patients.
• Identified patterns to help the care team in Plan of Care adjustments.
• Maintains documentation of enrollment process, including prospective participants within designed software programs as necessary to complete mandatory state statistical reporting functions.
• Assists Administrative staff with completion of reporting requirements.

Position Details

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Responsibilities