Apply

PACE Home Care Coordinator 
Syracuse, NY
​Our client is looking for a Home Care Coordinator RN to assist with care coordination of PACE participants; acts as the liaison for the interdisciplinary team between acute care facilities, congregate housing sites, the skilled nursing facilities, the contracted home care agency and various community settings where contracted services are provided; ensures appropriate paper work/communication is sent/received by contracted facilities as necessary to meet the ongoing care needs of participants.
Qualifications: 

• Bachelor’s degree in nursing
• Currently licensed as Registered Nurse in New York State
• Two (2) years of home care experience or a minimum of three (3) years’ experience in health care, preferably in long term care or working with geriatric population as hospital discharge planner, etc.
• Current knowledge of best practice nursing standards and care
• Ability to exercise good judgment and maintain confidentiality
• Proven patient assessment skills
• Proven organizational, time-management and interpersonal skills

Responsibilities: 

• Evaluates appropriateness of new referrals to ensure in-home care needs can be met and that the potential client can be safely maintained in home environment
• Makes home visits on new referrals during the initial assessment process; during the intake and assessment process works with interdisciplinary team and participant/family to develop an appropriate plan of care
• Follows participants in the hospital; calls the hospital discharge planner each business day or visits hospitalized participants as appropriate; reports immediately to provider if significant problem/change is noticed or reported
• Daily communicates with PACE CNY providers and hospitals/ hospital staff to assist in care coordination and to minimize hospital lengths of stay; works with interdisciplinary team and hospital discharge planner to coordinate a safe discharge and a smooth transition for participant from the hospital to home or to an alternate level of care; provides assistance and support to the participant and family during hospital stay; documents coordination of care in the medical record, may attend discharge meetings with the interdisciplinary team; coordinates need for a bed hold with the SNF, if necessary.
• Acts as a liaison with contracted home care agency to ensure home care agency is informed and has home care needs of participants as determined by the participant/caregiver and the PACE CNY team for new enrollees.
• Also acts as liaison for the interdisciplinary team and SNF staff and enriched living staff; may attend care planning meetings for SNF residents and participants who reside in an enriched living facility; may routinely visit/call contracted skilled nursing and enriched living facilities to review care needs, discuss participants’ status/progress updates and communicate/share information, i.e., family/participant/team goals, care plan updates, etc.; may also attend the reassessment meetings for long term care participants; may also visit contracted social day centers to observe participants in the environment, share information etc.
• Attends morning team meetings and provides status reports; shares pertinent information and communicates concerns/problems for team discussion and resolution as appropriate; completes assessments (SAMMs) every six months for participants residing in the SNF or EL facility; presents assessment to interdisciplinary team during team reassessment meeting for care planning purposes to ensure participant needs are met
• Documents all communication with contracted agencies’ personnel, participants, families, etc. such as potential discharge date, status reports, planning interventions, etc. in a thoroughly accurate professional manner; maintains records in a confidential organized manner.

SMV Recruiting provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, SMV Recruiting complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment.