Major Responsibilities:

Collaborates with both hospital and/or clinic caregivers as a resource regarding home care services and provides general education of services. Educates patients/families on home care, palliative care, and hospice services and is available to answer questions allowing patients to make an informed decision regarding their discharge plan for post-acute care. Regularly attends the outcome facilitation team meetings on the individual hospital units to provide input regarding services that could be provided in the home. Communicates with social workers or case managers on complex cases. Builds relationships of mutual respect with hospital and clinic based physicians, nurses, social workers, case managers, and community partners by providing good communication regarding patient transitions. Visits patients prior to discharge to ensure patients meet criteria for Centers for Medicare & Medicaid Services (CMS) regulations and has an understanding of provider orders for home care, palliative care, or hospice services upon patient selection of Aurora At Home as the provider of choice. Collects and records medical, social, and reimbursement data from the hospital and/or clinic record pertinent to initiating Aurora At Home home care, palliative, hospice, DME, RT, enteral, and infusion services. Follows Aurora At Home home care, palliative, and hospice patients readmitted to the hospital and evaluates their need for further services. Collaborates with hospital and/or clinic caregivers and patient/family regarding financial coverage of all Aurora At Home service lines, and if available, provides information prior to hospital discharge. Must be able to demonstrate 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. Licensure, Registration, and/or

Certification Required:

Registered Nurse license issued by the state in which the team member practices.

Education Required:

Associate's Degree in Nursing.

Experience Required:

Typically requires 3 years of experience in clinical nursing including experience with discharge planning and/or case management.

Knowledge, Skills & Abilities Required:

Excellent communication skills. Must be able to speak clearly and hear to communicate with people in person or over the telephone. Good organizational, analytical and problem solving skills. Proficiency in clinical skills with the ability to work under direction and make sound judgments. Demonstrated ability to educate clinical staff and the community. Demonstrated ability to work well with physicians and other professionals in a direct and positive manner. Ability to work in a team based environment and participate on multiple teams. Must have a thorough understanding of home care reimbursement to include Medicare, Medicaid and private insurance or ability to learn criteria. Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs. Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families.

Physical Requirements and Working Conditions:

Must be able to stand, sit and walk for prolonged periods of time as required to complete the referral process. Must have the physical ability to move about in confined spaces, including bending, twisting, kneeling, squatting and occasionally reaching one or both arms over head. Must be able to concentrate on minimal to minute detail with frequent interruptions and remember multiple cases, tasks and functions over a period that extends from minutes to hours and occasionally weeks at a time. Must have the ability to visually identify people, objects and files within a distance of three feet. Most work is performed in a temperature-controlled building. Exposure to hazardous chemicals or potentially infectious body fluids, loud noises or hazardous equipment occurs occasionally; therefore, protective clothing must be worn as necessary. Operates all equipment necessary to perform the job. 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.