Registered Nurse, Home Health Program Nurse Coordinator

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi‑site mission‑driven non‑profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley.

Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking an RN, Home Health Program Nurse Coordinator to join our team. The Home Health Program Nurse Coordinator (RN) works under the supervision of the Director of Population Health and serves as the central coordinator for all home health referrals within the organization. This role manages and monitors provider-initiated referrals to home health agencies to ensure timely initiation, appropriateness of services, and continuity of care.

The Home Health Program Nurse Coordinator acts as the primary liaison between medical providers, care teams, patients, and home health agencies and is critical in holding home health agencies accountable for delivering patient‑centered, high‑quality care aligned with clinical expectations and care plans. Works in collaboration with discharging facilities and care management teams to facilitate appropriate referrals for GLFHC patients.

This role oversees referral processing, monitors the progress of home health services, and supports the certification and recertification process to ensure services remain medically necessary and aligned with the patient’s care plan. This position plays an important role in supporting value‑based care, by promoting appropriate use of home health services, improving care coordination, and helping patients safely receive effective care in the home setting, helping to improve health outcomes while reducing unnecessary utilization and expenses.

This role does not provide direct care; it manages and oversees the Home Health Program in a care‑coordination role and does not include direct home health nursing visits or field‑based clinical care.

• Serve as a central access point for all referrals to home health providers, including evaluating medical necessities and appropriate utilization based on clinical acuity.
• Remain current in interpreting reimbursement guidelines to ensure patients’ services meet coverage criteria.
• Review provider‑initiated referrals to ensure completeness, clinical appropriateness, including medical necessity that aligns with payor requirements.
• Serve as a subject matter expert for the integrated care team, including working with nursing to facilitate home health referrals.
• Coordinate with providers and care teams to obtain necessary documentation required for home health services.
• Maintain an organized tracking system for all active referrals and home health services.

• Serve as the primary point of contact for home health agencies, facilitating communication between agencies, providers, and care teams.
• Monitor the initialing and progress of home health services to ensure timely start of cases and adherence to the prescribed care plan.
• Follow up with agencies regarding delays in care initiation, missed visits, or deviations from expected service plans.
• Escalate concerns regarding patient safety, services delays, or agency performance to appropriate providers or leadership.
• In collaboration with home health providers, develop relationships and conduct ongoing assessments of their clinical capability based on the population served.

• Track all active home health referrals and services, maintaining an accurate registry to monitor patient progress and engagement.
• Follow up with providers and home health agencies to ensure completion of required documentation, orders, and care plans.
• Review agency updates and documentation to determine whether services continue to meet medical necessity requirements.

• Collaborate with the integrated care team including case managers,…