RN Coordinator - Home Care

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke HomeCare & Hospice

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

Schedule:  Ten-hour shifts (8 AM to 6:30 PM), Friday, Saturday, Sunday, Monday

The RN Coordinator is a dynamic, fast-paced role supporting home health, hospice, and infusion services. The primary focus is coordinating patient referrals at Duke University Hospital on weekends, with opportunities to support all three hospitals during weekday shifts.

This role assesses home care needs, educates patients and caregivers on safe and effective home health and hospice services and infusion devices, and partners closely with interdisciplinary teams, referral sources, and community providers to ensure seamless, high-quality transitions of care.

The ideal candidate thrives in complex care environments, builds strong relationships across disciplines, and is passionate about connecting patients and families to the services they need at home.

MAJOR JOB RESPONSIBILITIES

Clinical Care Coordination
1. Utilize comprehensive assessment skills to determine a patient’s appropriateness for home care, initiate the appropriate home program referral, and provide patient/family education related to the initiation of home care services. 

2. During patient/family education, identify any barriers or concerns related to home care by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Communicate the identified concerns to the Case Manager or physician team to develop a comprehensive discharge plan.
3. Provide ongoing daily assessment and monitoring of patient referrals until discharge to ensure all patients have the appropriate services, including ongoing home support. Coordinate with the hospital Case Manager to request additional services/orders.

4. Maintain effective communication with the health care team related to assessment findings, additional discharge planning needs, and during patient/family education.
5. Electronically document all activity in Maestro and CareTend and other documentation systems relevant to the position.
6. Meet with referral sources regularly to identify gaps in care, patient population needs, opportunities for referral process improvement, and ongoing identification of additional patient/staff educational opportunities. 

7. Maintain a working knowledge of specific insurance benefits, reimbursement guidelines, and maintain an understanding of their impact on the delivery of home health, hospice, and infusion services.
8. Maintain a working knowledge of applicable federal and state regulatory guidelines related to home care services
9. Maintain a current knowledge base of the comprehensive services, products, and supplies available through DHCH.
10. Work with DHCH referral center, finance, and the appropriate home program to accurately complete and obtain any additional required documentation to facilitate the prevention of an insurance denial for services.
11. Develop and maintain a positive relationship with internal and external customers.
12. Job responsibilities may include site-specific duties, weekend/holiday or after-hours coverage as designated at each entity.
13. Perform other related duties incidental to the work described herein.

Education and Certification:

BSN required. Current RN licensure in the state of North Carolina, or compact licensure in participating state is required.

BLS required, may be renewed during orientation.

Work Experience:

Three years of nursing experience are required.