This role is to provide home visits to patients in Lackawanna County.Works with physician and multidisciplinary team members to develop plan of care for each assigned patient from admission through discharge. Ensure patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and evaluations. Assess and respond to patient and family needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care.
Works in conjunction with physicians, nurses, inter disciplinary team and others to assess, plan and initiate patient plan of care.
Facilitates and coordinates details of the actual discharge to appropriate agencies.
Facilitates and coordinates an individualized care coordination plan.
Serves as a resource to physician and hospital personnel regarding available agency, facility, and community services to assist in discharge planning.
Completes appropriate federal, state and local forms.
Ensures adherence to quality standards and participation in quality monitoring and improvement by monitoring quality of care using predetermined criteria, reporting potential risk and quality management issues identified from medical record review to appropriate departments through defined processes, and enters data as requested and appropriate for role, to support quality improvement initiatives into appropriate system.
Conducts on-going case review for delays or variances in care; raises issues with appropriate department, attending physician and physician designee.
Captures data per department policy.
Communicates to appropriate physician identified issues for resolution and intervention.
Uses approved medical necessity criteria as a tool to ensure that patients meet appropriateness of the setting.
Actively involves payer liaison role in any case that has potential of not meeting medical necessity guidelines.
Supports payer liaison role to resolve barriers through appropriate administrative and medical channels to avoid third party payer denials.
Maintains awareness of all concurrent denials through interaction with payer liaison.
Works with payer liaison to facilitate timely discharge or alternative plan of care acceptable to physician, family and payer.
Work is typically performed in a clinical and office 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.
Graduate from Specialty Training Program-Nursing (Required), Bachelor's Degree-Healthcare Related Degree (Preferred)
Minimum of 3 years-Nursing (Required)
Certification(s) and License(s)
Basic Life Support Certification - American Heart Association (AHA); Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.