Post-Acute Optimization Coordinator

Salary Range $43.36 - $67.84 Overview Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members. Employees of Confluence Health receive a wide range of benefits in addition to compensation. Medical, Dental & Vision Insurance Flexible Spending Accounts & Health Saving Accounts Paid Time Off Generous Retirement Plans Life Insurance Long-Term Disability Gym Membership Discount Tuition Reimbursement Employee Assistance Program Adoption Assistance Shift Differential For more information on our Benefits & Perks, click here! Summary Under the direction of the Home Care Services Director and Clinical Manager, the Post-Acute Optimization Coordinator is an integrated position responsible for hospital‑based hospice identification and GIP conversion, ACO SNF patient management and utilization reduction, and home health referral optimization and growth. This role directly supports Confluence Health’s goals related to Risk‑Adjusted Mortality Index (RAMI) improvement, ACO shared savings, revenue growth in home health and hospice, and site‑of‑care optimization. This position works daily with the Hospital Case Managers, Hospitalists, Physical Therapies, Hospice, Home Health, Population Health/ACO leadership, and the Palliative Care Team to ensure that patients who are identified as needing Home Health or Hospice are consulted on and referrals are made, after giving patient the choice, to the appropriate Agency. This will be accomplished through attending MDT rounds on all acute floors and through an order by the physician in charge of the patient. Position Reports To: Home Care Services Director Essential Functions Provides in-patient consultation services and overall coordination of identified/referred Home Care (Home Health/Hospice) patients. Assist in early identification of hospice‑appropriate patients. Real‑time collaboration with hospitalists and case managers. Support the patient/family in care options and goals of care conversations. Facilitation of timely hospice election for all levels of care. Facilitate appropriate admission to GIP level of care. Performs hospice comprehensive assessment for GIP appropriate admissions. Facilitate and coordinate timely discharge to hospice services. Proactive review of patients being considered for SNF placement. Early identification of patients who can safely discharge home with Home Health. Earlier hospice engagement for SNF patients nearing end of life. Collaboration with therapy services to support home‑based discharge planning. Increased capture of appropriate Home Health referrals. Assists with discharge planning to home or other facility and notify Home Health agency of choice of pending referral. Attends the length of stay meetings and provides input. Participates in the Multidisciplinary rounds on ICU, PCU, MOU, SOU. Coordinates timely visits by collaborating with Intake Referral Coordinators of Home Health or Hospice agencies. Collects and maintains data to evaluate the quality of the Post Acute Optimization Coordinator program. Provide training/education to patients and family on basic care needs, medications, and the level of service provided by home health or hospice agencies. Is actively involved in quality improvement processes by participating in performance improvement projects, committees, review of policy, chart audits, and other projects as needed. Maintain Basic Life Support (CPR) certification. Performs other duties as assigned. Demonstrate standards of behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Qualifications Required: Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499). 3 years clinical experience in home health. Professional certification in area of expertise, if available, or commitment to obtain certification. Basic Life Support (CPR) certification (within 90 days of hire). Desired: Bachelor’s Degree in nursing (BSN). CHPN Certification. Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday. F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday. C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday. Physical/Sensory Demands For This Position: Walking - C Sitting/Standing - F Reaching: Shoulder Height - F Reaching: Above shoulder height - O Reaching: Below shoulder height - F Climbing - O Pulling/Pushing: 25 pounds or less - F Pulling/Pushing: 25 pounds to 50 pounds - O Pulling/Pushing: Over 50 pounds - O Lifting: 25 pounds or less - F Lifting: 25 pounds to 50 pounds - O Lifting: Over 50 pounds - O Carrying: 25 pounds or less - F Carrying: 25 pounds to 50 pounds - O Carrying: Over 50 pounds - O Crawling/Kneeling - O Bending/Stooping/Crouching - F Twisting/Turning - F Repetitive Movement - O Working Conditions: Work is performed primarily in the hospital but may also include the patient’s home environment or a community facility. May also work from the office as needed. Involves continuous contact with patients. Interaction is constant with frequent interruptions. Contact involves dealing with ill people. Driving in all seasons of weather. Job Classification: FLSA : Non-Exempt Hourly/Salary : Hourly Physical Exposures For This Position: Unprotected Heights - Yes Heat - Yes Cold -Yes Mechanical Hazards - Yes Hazardous Substances - Yes Blood Borne Pathogens Exposure Potential - Yes Lighting - Yes Noise - Yes Ionizing/Non-Ionizing Radiation - No Infectious Diseases - Yes Provides in-patient consultation services and overall coordination of identified/referred Home Care (Home Health/Hospice) patients. Assist in early identification of hospice‑appropriate patients. Real‑time collaboration with hospitalists and case managers. Support the patient/family in care options and goals of care conversations. Facilitation of timely hospice election for all levels of care. Facilitate appropriate admission to GIP level of care. Performs hospice comprehensive assessment for GIP appropriate admissions. Facilitate and coordinate timely discharge to hospice services. Proactive review of patients being considered for SNF placement. Early identification of patients who can safely discharge home with Home Health. Earlier hospice engagement for SNF patients nearing end of life. Collaboration with therapy services to support home‑based discharge planning. Increased capture of appropriate Home Health referrals. Assists with discharge planning to home or other facility and notify Home Health agency of choice of pending referral. Attends the length of stay meetings and provides input. Participates in the Multidisciplinary rounds on ICU, PCU, MOU, SOU. Coordinates timely visits by collaborating with Intake Referral Coordinators of Home Health or Hospice agencies. Collects and maintains data to evaluate the quality of the Post Acute Optimization Coordinator program. Provide training/education to patients and family on basic care needs, medications, and the level of service provided by home health or hospice agencies. Is actively involved in quality improvement processes by participating in performance improvement projects, committees, review of policy, chart audits, and other projects as needed. Maintain Basic Life Support (CPR) certification. Performs other duties as assigned. Demonstrate standards of behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Required: Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499). 3 years clinical experience in home health. Professional certification in area of expertise, if available, or commitment to obtain certification. Basic Life Support (CPR) certification (within 90 days of hire). Desired: Bachelor's Degree in nursing (BSN). CHPN Certification.