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Position Summary

Registered Nurse required. Home Infusion experience highly preferred.

The Home Infusion Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Infusion Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Home Infusion Care Transition Coordinator navigates getting patients into the right care at the right time.

Position Specific Responsibilities

• Regularly meets with physicians in the hospital to discuss specific patients:
  • Documents interaction in CPR+
  • Gives guidance and provides an understanding of post-acute service support
  • Ensures continuity of care as a priority
  • Communicates data sets to clinicians (e.g., predictive analytics, prognostic scores)
• Hospital case managers (rounding or interactions in step with hospital):
  • High-risk patient reviews
  • Aligns with the cadence of patient review - prognostication, data analytics, risk-profiling
• Collaborates with case managers, social workers, discharge planners, and physicians to facilitate early identification of discharge candidates.
• Develops genuine collegial relationships with other Healthcare professionals:
  • Identifies times and meets regularly with clinicians to problem-solve, review cases
  • Interacts with discharge planners/case managers and physicians to assist in developing patient care plans in alternate sites of care
• Capacity to conduct and complete Goals of Care discussions/Advance Care Planning/Resuscitative preferences.
• Understands disease trajectories and explains the risk/benefits of treatments.
• Educates and trains referral sources and caregivers for the transition of patient care from acute setting to alternative site of care.
• Understands how to interact with difficult patients/families.
• Demonstrates a working knowledge of local market health plans and a general understanding of cost containment concepts.
• Maintains a current list of admission coordinators for each healthcare service line.
• Aligns recommendations between patient/family and Primary care team:
  • Identifies patient preferences/needs
  • Identifies patient's post-acute care needs
  • Confirms the level of care most appropriate for the patient - right care, right time
  • Educates patient on Homebound criteria and verifies patient meets these requirements
  • Facilitates 'transition to home' planning including assessing post-discharge needs and developing and implementing a transition to home plan
• Sets patient-centered goals and facilitating transitions:
  • Understands how to identify patient/family-specific treatment goals
• Arranges for home admission and communicates with the Home Infusion team.
• Coordinates patient care by obtaining H&P, physician orders, hospital records, and face-to-face documentation in a timely manner.
• Verifies patient demographic information is correct.
• Coordinates the organization of transfer orders and educates patients on home infusion orders and services.
• Assists Home Infusion Account Executive in achieving territory growth plan and profitability.
• Conducts follow-up on re-hospitalized of home infusion patients.
• Provides clinical support for Ambulatory Infusion Centers, as applicable.
• Understands and complies with regulations and recommendations of outside regulatory and accrediting bodies, and third-party payers pertaining to precertification.
• Develops ability to understand and digest claims data, and use of predictive analytics.
• Ensures excellent customer service to maintain and grow the business in the identified key accounts.
• Consistently works to improve personal knowledge and growth skills to become of greater value to our most important customers and to the organization.
• Meets or exceeds assigned quotas, thereby maintaining and constantly improving the Pharmacy competitive position.
• Assists and/or participates in other clinical and growth activities as directed by the Director of Operations or VP of Operations.
• Performs other duties as assigned.

Education and/or Experience

• Associate or Bachelor's degree in Nursing required.
• Experience in infusion healthcare marketing preferred.
• Minimum of two (2) year's of experience in infusion healthcare preferred.
• Sales experience preferred.
• Experience with Medicare Home Infusion Benefit - skilled need, homebound status determination.

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Other Skills and Abilities: Ability to complete a patient assessment, have venous access skills. Knowledge of standard practices for all services offered (ACHC standards). Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Strong understanding of Infusion/Specialty Pharmacy.

Certifications, Licenses, and Registrations

• Active and unencumbered Registered Nurse license in state(s) of employment required.
• Current CPR certification required.

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.
At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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