Johns Hopkins Bayview Medical Center
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Home Care Coordinator/Discharge Planner

Specific Duties and Responsibilities:
  • Reports to the Clinical Manager
  • Acts as a discharge planning resource to hospital staff involved in home care planning
  • Facilitates continuity of care for the patient transitioning to home based services
  • Serves as on-site home-based care expert
  • Has thorough understanding of available home care services and products, eligibility requirements, and resources available in the community
Job Requirements:
  • AA in Nursing required, BSN preferred
  • Two or three years home care or home care discharge planning experience preferred
  • Home care experience preferred
  • Current licensure as RN in Maryland
  • Current CPR certification

Home Care Nurse Liaison (Adult & Pediatrics)

Specific Duties and Responsibilities:
  • Requires a licensed nurse who has a thorough understanding of available home-based services and products, eligibility requirements, and resources available in the community.
  • Acts as a resource to Hospital/Facility staff involved in home care planning, and facilitates continuity of care as the patient transitions to home-based services.
  • Actively involved in marketing activities and the presentation of educational programs to build revenue and promote the continuum of care needs for patients.
Job Requirements:
  • Graduate of accredited program required; BSN preferred
  • Thorough knowledge of home care (home health, infusion, and medical respiratory and equipment) eligibility requirements, agency policy and procedures, federal and state regulations and third party regulations for reimbursement of home care services
  • Thorough knowledge of marketing and sales principles

RN Home Support

Specific Duties and Responsibilities:
  • Provides safe, therapeutic patient care through the use of the nursing process.
  • Coordinates, teaches and supervises patient care for a group of private patients, usually in the setting of the patient's home, and provide supervision, guidance and support of personal care providers, CNAs and per diem LPNs and RNs, Intake and Scheduling staff.
  • Promotes the company to targeted referral sources throughout the community, coordinating referrals and ensuring adequate service provision including scheduling based on patient's identified needs and priorities for care.
Job Requirements:
  • Graduate of accredited program required; BSN preferred
  • RN in the State of Maryland and CPR
  • Two years’ home care or private duty experience required
  • Thorough knowledge of home care (home health, infusion, and medical respiratory and equipment) eligibility requirements, agency policy and procedures, federal and state regulations and third party regulations for reimbursement of home care services
  • Thorough knowledge of private duty policies and procedures

Transition Guide RN

Specific Duties and Responsibilities:
  • Reports to the Transition Programs Manager
  • Acts as a coach to patient with chronic or complex conditions who are at risk for multiple hospital readmission
  • Helps patient transition from the inpatient setting to their home and stay safely there by assisting in navigating the health care system while encouraging independence towards better self-management of their health
  • Monitors, case manages the patient’s progress through follow up phone calls and home visits Provides the following model of care:
      • medication self-management
      • developing and adhering to the patient-centered health record
      • ensuring follow-up appointments are scheduled with the primary care provider/specialist
      • educating the patient or caregiver about disease processes and interventions as well as "red flag symptoms"
Job Requirements:
  • AA in Nursing required, BSN preferred
  • Two or three years home care experience preferred
  • Completion of the Guided Care Certification Course or matriculating towards completion within one year
  • Current licensure as RN in Maryland
  • Current CPR certification

Clinical Review Nurse

Specific Duties and Responsibilities:
  • Supports clinical quality and reimbursement through documentation or chart review, staff education, field supervision and performance improvement activities
Job Requirements:
  • BS or higher nursing degree preferred
  • Competent and knowledgeable in Medicare Conditions of Participation, JCAHO standards for home care, MD State Licensure regulations, and reimbursement requirements for Medicare, Medicaid and other payers
  • Knowledgeable in ICD-10 coding guidelines
  • In depth knowledge of OASIS
  • Current licensure as RN in Maryland
  • ICD-10 certification preferred
  • OASUS COS-C certification preferred