Job Profile Summary
?This role focuses on performing activities associated with evaluating, developing, recommending, implementing, and carrying out the policies and procedures related to the delivery of high quality patient care. In addition, this role focuses on performing the following Care Navigation related duties include: Focuses on the patient's needs and helps guide the patient through the healthcare system and works to overcome obstacles that are in the way of the patient receiving the care and treatment they require. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience. Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices.
Job Overview
Serves as a resource for referral sources and the public regarding services provided, third party regulations, determination of home care eligibility, and appropriateness for home care. Provides resource information if patient/client is not eligible or not appropriate for home care.
Job Description
Minimum Qualifications :
Massachusetts RN Licensure and NH Licensure.
Two (2) years of visiting nurse experience.
Duties and Responsibilities : The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.
Obtains the necessary patient identification, medical and financial information required for the nurse and/or therapist to make the initial home health visit.
Documents important information on the agency's "Request for Service" form creates a case in Forcura and the current EMR.
Attempts to assess if the potential patient can manage safely in their home and assists referral source in making decisions regarding safe discharge planning.
Assesses if the patient is eligible for home health services under their payment source. Try to establish Home Bound status and if medically necessary/reasonable requests.
Effectively manages HHVNA and Hospice referrals for patients who do not have insurance coverage for requested services and consults with other RNs as needed. Communicates the mission of the agency to provide care for patients regardless of ability to pay, and manages expectations about the available services.
Provides information of other community resources to the referring party if needed and if patient does not meet home care criteria.
Communicates with billing to verify atypical insurances as requested by referral sources and to support UR and Clinical Staff.
Identifies pre-admit evaluated patients and works to determine home care eligibility and appropriateness for home care. Communicates with department manager to determine acceptance of referral.
Follows referral department guidelines regarding orders required to initiate home health services. All physician orders/approvals are noted in the referral orders.
Prioritizes completion of referrals based on clinical priority, patient safety, and insurance precertification.
Effectively manage the time it takes to complete referrals by understanding what information is desirable vs necessary.
Uses critical thinking and problem-solving skills to resolve referral issues limiting the need to involve the referral source.
Utilizes clinical judgment to determine optimal services to manage a patient safely in the home setting.
Adheres to referral order documentation guidelines developed to guide agency initiatives.
Maintains productivity standards as defined by the department standards.
Obtains prior authorizations and pre-certifications as required by insurer.
Completes e-tracking and Forcura case final verification to inform clinical departments on admission state, diagnoses and priority of ordered care.
Keep the Intake clinical manager informed of any problems communicated by referral sources.
Report any changes or trends noted in referral patterns to Department manager.
Keep abreast of third-party regulations and insurance companies and HMO's.
Identifies opportunities to generate potential referrals for all agency services to meet the care needs of the patient.
Demonstrates required knowledge of Home Health Foundation services for which a patient may be eligible.
Selects the correct referral sources in the referral source tab to enable accurate data collection.
Keeps department Clinical Lead informed of issues related to workflow.
Reaches out to other RNs and/or Intake Clinical Manager to determine if a referral is to be accepted or declined.
Reports Compliance concerns to the CEO or Chief Compliance Officer when applicable.
Physical Requirements :
Frequently required to move about inside the office to access file cabinets, office machinery, etc.
Ability to remain in a stationary position 90% of the time.
Occasionally lifts and/or move up to 10-25 pounds.
Constantly operates a computer and other standard office equipment such as copy machine, phones, photocopier, fax machines and computer printers.
Specific vision abilities apply including close vision, distance vision and ability to adjust focus.
Noise level in the work environment is usually moderate.
Skills & Abilities:
Ability to function well in very busy situations.
Responsible and reliable.
Good organizational skills.
Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org .
