Position Summary: To receive, evaluate, facilitate, and manage inquiries and referrals for agency services from all sources and facilitate the transition of patients from an on-site unit of a hospital or skilled nursing facility to the home.

Reports To: Director of Intake and Service Development

Duties and Responsibilities:
GENERAL
1. Represents agency in a professional manner and promotes agency mission
2. Serves as a liaison between facilities and home health agency staff regarding patients, policies and staff.
3. Assists with the exploration, identification and evaluation of present and potential needs and resources in relation to the community health program.
4. Identifies potential referral sources in the community and assists with increasing agency visibility.
5. Identifies the availability of community resources and utilizes those that best meet the needs of patients in the home setting.
6. Attends mandatory meetings, inservices, and maintains agency standard for annual inservice hours
7. Adheres to all applicable federal, state, local laws and regulations.
8. Provide coverage for Certified Home Health Agency Intake as needed.
9. Other duties as assigned

REFERRAL PROCESS
1. Evaluates patients referred for home care/hospice care and appropriately identifies:

Need presented for services within scope of all disciplines available and with consideration of medical history, functional ability, availability of caregiver, and interventions needed.

Patient mobility, safety, and homebound status.

Patient's request for home care/hospice care

2. Consults with physicians, nurses, social workers and other disciplines while establishing a coordinated home care plan prior to discharge from a facility or from the home.
3. Ensures appropriate physician oversight of patient Care as per VNSHS and the Federal Guidelines by verifying the community MD identified by patient and confirming credentials of said MD..
4. Interacts with patients and their families, explaining scope of program and services
5. Obtains complete and accurate physicians orders for all patients who require care, with specific orders for treatments including but not limited to wound care, diabetic management, medications, and/or foley care required
6. Assesses patient need and arrange for DME, supplies, and/or lab work needed to implement care plan in the home
7. Interacts with patients and their families, explaining scope of program and services
8. Obtains complete and accurate physicians orders for all patients who require care, with specific orders for treatments including but not limited to wound care, diabetic management, medications, and/or foley care required
9. Assesses patient need and arrange for DME, supplies, and/or lab work needed to implement care plan in the home

INTERACTION WITH AGENCY
1. Coordinates with clinical staff to inform of patient acceptance of home care/hospice, and provide complete and accurate intake data, including but not limited to history, emergency contact information, care plan and signed medical orders.
2. Confers with agency personnel on patient progress of pending referrals.
3. Communicates with clinical managers regarding staff availability
4. Collects and maintains statistical data on all referred patients and submits them on a monthly basis to the Director.
5. Assists in the orientation of new staff and nursing students, as assigned.
6. Participates in performance improvement activities and orientation of new agency staff.
7. Seeks supervisory input regarding appropriateness of referrals when questionable.
8. Demonstrates flexibility in covering other Intake colleagues in support of efficient Intake staffing when requested.
9. Provides daily reports to supervisor regarding caseload of pending referrals.
10. Attends mandatory meetings and maintains agency standard for yearly inservice.
11, Complies with documentation required by payment source including but not limited to Medicare and obtains required documentation such as Face to Face Document.

INTERACTION WITH REFERRAL SOURCES
1. Provides feedback to professional referral sources such as hospitals and facilities.
2. Serves as a resource to facility providers regarding community resources and home care/hospice issues and practices.
3. Offers in-service to referral sources including but not limited to facilities and community service agencies. regarding home care/hospice services.
4. Demonstrates effective communication skills with other agency team members/departments.

Qualifications:
License and current registration to practice as a registered professional nurse in NYS.
Bachelor's Degree from an accredited program in nursing preferred.
One year nursing experience in acute care setting and in a certified home health agency.
Knowledge of community health nursing principles and practices.
Knowledge of current practice treatments methods by which this care may be extended into the home.
Demonstrated organizational and communication skills and adeptness utilizing computers and navigating related software.
Ability to interpret home health agency policies to hospital personnel.