NYC Health + Hospitals/Community Care reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Work Shifts
9:00 A.M - 5:00 P.M (37.5 Per Week)
Duties & Responsibilities
Purpose of Position:
Under general supervision, with varying degrees of latitude for independent initiative and judgment, coordinates and monitors the management of patient-centered quality care, ensuring optimal utilization of resources, service delivery, and compliance with external review requirements and applicable state and federal rules and regulations and nursing standards of care for better outcomes and improved patient experience. Facilitates patient's progress from admission through discharge, and promotes strategies and forums for collaboration and mutual problem solving.
Examples of Typical Tasks: 1. Reviews each patient's chart. Ensures that documentation in the medical record supports plan of care and justifies admission and continued stay. 2. Coordinates and/or participates in multidisciplinary rounds; reviews plan of care; and discusses estimated length of stay, need for continued hospitalization and appropriateness of resources utilization, consultations, treatment plan and discharge plan. Completes Patient Review Instrument (PRI). 3. Collaborates and consults with physicians and other health care professionals to reach an efficient pathway of care taking and to identify, eliminate, and implement solutions to barriers, and collects and analyzes related data, as needed. 4. Communicates with Health care setting investigation/reimbursement department and third-party payers to obtain authorizations and ensure appropriate reimbursement, and provides clinical reviews and updates to managed care companies, as needed. 5. Plans and implements strategies to reduce length of stay, reduce resource consumption, and achieve positive client/patient outcomes. May coordinate the implementation of health care setting initiatives designed to increase revenue. Maintains all related records and documentation. 6. Initiates discharge planning by assessing client/patient and family needs, including but not limited to identifying non-medical psychosocial needs and post discharge medical needs. Informs patient and family of discharge planning options based on diagnosis, prognoses, resources and preferences related to home care services. 7. Coordinates and facilitates timely implementation of discharge plans for patient; assures timely completion of discharge, transfer and referral forms, prescriptions, and discharge orders; arranges follow-up care, as appropriate. 8. Performs or coordinates the post Emergency Department discharge phone call to patient and health care providers to facilitate/coordinate and verify that successful linkage to care occurred. 9. Maintains effective communication with physicians, nursing staff, clients/patients, families and others related to discharge planning; coordinates with social services personnel to provide needed services. 10. Contacts and directly engages patient's primary care physician and/or health care providers to support continuity of care and effective care transition. 11. May interview, orient, train, mentor and coach new care management staff, and coordinate and supervise the performance of care coordinators and social work staff performing discharge planning and assessment. 12. May collaborate in the development of departmental policies and procedures, clinical practice guidelines and critical pathways for designated targeted diagnosis. 13. May act as an educational resource and provide consultation regarding case management, discharge planning process, clinical documentation requirements and applicable federal, state and local regulations; may identify benefits, implications, and limitations of home care.
Minimum Qualifications 1. Valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Education Department (NYSED); and 2. A Baccalaureate degree in Nursing or related health field from an accredited college or university; and 3. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA); and 4. Two (2) years of experience as a Registered Professional Nurse.
Department Preferences 1. Assesses quality of care by varying methods including but not limited to chart audits, and reviews of OASIS assessments and plans of care, etc. Completes reviews of OASIS assessments in assigned Epic work queues utilizing and incorporating quality assurance data from third party vendors, including Strategic Health Programs (SHP), McBee, etc. 2. Updates/revises and finalizes the patient's plan of care with written input from patient/caregiver, physician and other multidisciplinary health team members. 3. Participates in performance improvement activities, utilization review, and quality assurance and performance improvement (QAPI) program including the QAPI Committee. Assists in the development, planning, implementation, monitoring and evaluation of QAPI initiatives and tools. 4. Participates in the development, planning/coordination, implementation, monitoring and evaluation of QAPI content for new employee orientation and continuing education for all nursing staff; and coordinates with appropriate clinical resources. 5. Assists with the development and implementation of policies and procedures, standard operating procedures and guidelines to aid compliance with federal, state and local regulations and accreditation standards. 6. Assists with QAPI data collection, analysis, and provides insight on patient issues. Collaborates with clinical managers and directors to identify process measures and outcomes needing improvement plans. Coordinates appropriate communication and documentation between clinical and administrative staff and provides feedback to clinical leadership on all aspects of QAPI initiatives. 7. Participates in comprehensives reviews/investigations of all incidents, complaints, infection control logs, and potentially avoidable events. Identifies incidents that will require a root cause analysis. Reviews the clinical records, establish the event time-line, and may serve as the facilitator of those cases requiring a multi disciplinary team meeting. 8. Identifies trends and opportunities for improvement based on findings of reviews/investigations and establishes action plans for outcome measures requiring improvement including those identified in SHP and McBee reports. 9. Continuously analyzes work flow processes and makes suggestions for improvement and continuously improves knowledge base of QAPI in health care. Monitors and evaluates nursing documentation, and suggest revisions to clinical documentation system. Participates in special projects, focus audits and provides outcome data analyses. 1O. Ensures regulatory standards and compliance. Maintains absolute privacy, confidentiality and security of all information pertain n to employees and patients. Adheres to health s stem and Community Care policies. 11. Performs other duties to promote patient care management as assigned.
KNOWLEDGEABLE IN: A satisfactory equivalent of education and experience. However, all candidates must be licensed and currently registered to practice as a Professional Nurse in New York State. Demonstrated knowledge regarding Federal, State and local regulations and JCAHO standards for Home Care. Excellent verbal, written, organizational and analytical skills. YEARS OF EXPERIENCE: Minimum two (2) years of experience in a Certified Home Health Agency Minimum of 2 years of Public/Community Health and 2 years medical/surgical experience required. MRDD experience preferred. Previous experience in Pl, i.e., knowledge of Pl applications, tools and techniques and knowledge of the development, coordination and facilitation of Pl programs.
Additional Salary Compensation
In addition to base compensation, you may also receive the following based on the Collectively-Bargained Agreement:
An annual education differential if you currently possess an appropriate degree in nursing or an allied health discipline from an accredited college or university, as listed below:

• Bachelors of Science in Nursing (BSN) = $900
• Masters in allied health discipline = $1,200
• Masters of Science in Nursing (MSN) = $2,000
• Doctorate in Education, Nursing Practice or PhD in Nursing (DNP) = $2,500

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program
• Union Benefits for eligible titles
• Multiple employee discounts programs
• Commuter Benefits Programs