Home Care Coordinator; LVN​/RN

Home Care Coordinator (LVN/RN)

Alhambra, CA

Under the supervision of the Clinic RN, the Home Care Coordinator (LVN/RN) provides home-based nursing services under the LVN or RN scope of practice and coordinates home care services that support Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) that are essential for helping PACE participants maintain their independence and quality of life while living at home.

• Performs duties and responsibilities in conformance with state and federal regulatory requirements, Seen Health Policy & Procedures, and Quality Improvement and Compliance guidelines.
• Handles incoming calls related to participant inquiries, primary care provider orders, and referrals, ensuring effective communication with participants, care team members, and external agencies.

Home Care Services:

• Coordinates home care services as assessed by Case Management RN and approved by Primary Care Provider. Coordinates home care schedules with subcontracted Home Care Services provider.
• Submits home care request and authorization forms to subcontracted agency. Reviews service confirmation for accuracy and alignment with IDT approved services.
• Provides education to participant, caregivers or family members regarding the scope of approved home care services, as indicated on the participant care plan.
• Serves as the primary contact for contracted agencies regarding referrals, authorizations and scheduling.
• Maintains complete participant medical records with the timely requisition of home care service records and upload to the participant medical record.
• Conducts quality checks ensuring that home care services are rolled out as indicated on participant care plan. Collaborates with Case Management RN to remedy service issues.
• Provides training to agency caregivers and conducts initial competency assessments prior to subcontracted staff providing direct participant care. Conducts annual caregiver competency activities.
• Conducts QI and Utilization Management activities, tracking the effectuation of home care services and assisting with remediation for service interruptions and/or under/over utilization of services.

Nursing Services in Home Setting:

• Performs physical evaluation, including vital signs and blood glucose monitoring in the Home
• Documents observations of participant's condition during every visit and in patient health record within required time frames.
• Reports changes in condition to Clinic RN Manager and Case Management RN.
• Completes medication reconciliation and basic wound care as prescribed.
• Promptly notifies Primary Care Provider and other IDT members of changes in participant's condition including any wounds, physical or behavioral changes.
• Administers medication, screening tests, and immunizations as prescribed.
• Communicates to RN Case Manager and IDT when objective findings indicate that DME, home care assistance, or nutritional services would improve participant's quality of life and ability to live in the community.
• Communicates participant wishes, concerns and service requests to the RN Case Manager and IDT. Reviews and addresses home care concerns promptly, ensuring timely follow-ups and documentation of participant changes.
• Communicates effectively in the medical record and with all members of the home care team and other program staff to ensure that the participants are receiving care that is appropriate.
• Participates in interdisciplinary team meetings, contributes to care planning, and communicates participant updates effectively.
• Performs other duties as assigned

• Minimum of two (2) years of demonstrated successful experience in home care; prefer in-home care management experience.
• Minimum of one (1) year of documented experience working with a frail or elderly population.
• LVN preferred, minimum of two (2) years of nursing experience

• Regular travel to different settings in the community, primarily potential and current participant homes.
• In center at Seen Health in Alhambra, CA