Coordinates services of hospital/emergency room follow-up care.  Provides assessment, planning, coordination, and advocacy services for patients.  Provides non-clinical educational information, wellness programs and organizes related services for the patient while in the clinic or community setting.  Familiar with all programs to provide office support and continuity of care for various patient populations. 

1. Coordinates hospital and emergency department follow up care.

1. Serves as a liaison between VNA inpatients at the hospital and the VNA clinic to coordinate patient primary care services.
2. Face to face patient contact at hospitals, clinics and patient homes as indicated.
3. Communicates with hospitals and on-call staff to track patient hospitalization, status and discharge information.
4. Participates in hospital “care team” meetings to present VNA information regarding services, health plan participation and program updates.
5. Meets all VNA and hospital credentialing criteria for hospital rounding.
6. Rounds on all postpartum/newborn and hospital inpatients daily, or as indicated and prepares parents of newborns for child's first appointment.
7. Coordinate clinic follow up appointments for patients by ensuring appointments at the clinic are made prior to discharge from the hospital, if possible.
8. Ensure discharge summary, test results, etc. are available for providers at follow up appointments.
9. Inform patient of available resources and assist the patient in making appointments as needed.
10. Refers patient/Family to RN for health education materials and coordinates patient health education through community resources.
11. Provides patient education materials to promote patient compliance.
12. Coordinates services to ensure screenings are completed, and coordinates care to higher level depending on results.
13. Inform patient of available resources and assist the patient in making appointments as needed.
14. Evaluates effectiveness of health education, wellness-screening reminders and coordinates additional education and care as needed.
15. Assists with Home Health/Hospice intake process by following up with patient referrals from various hospitals and their referral platform to determine eligibility for Home Health/Hospice services. Follows work flow and completes intake process to prepare patient for admission to VNA.
16. Tracks and documents information about effectiveness of care and outcomes of referrals.
17. Understands and practices exposure control procedures as well as patient safety.
18. Indicates an interest in personal growth and VNA mission/goals and participates in staff meeting/in-services.
19. Familiarizes and complies with all VNA policies and procedures.
20. Meets standards of behavior expectations.
21. Follows established guidelines for use and/or disclosure of protected health information. Employees should report any breaches of the Health Insurance Portability and Accountability Act (HIPAA) rules to the Privacy Officer immediately. Failure to comply with HIPAA policies and procedures will result in disciplinary action, up to and including termination of employment.
22. Other duties as assigned.
23. Documents in the patient’s electronic medical record (EMR) all instructions and follow-up contact including notification of specialty referral appointments, testing, reminder calls, and follow-up calls after appointment or testing to ensure patient compliance.
24. Ability to work all Health Center hours as directed by the Director of Population Health Services.
25. Ability to work effectively and efficiently in the EMR.
26. Familiarizes and complies with all VNA policies and procedures.
27. Indicates an interest in personal growth and VNA mission/goals and participates in staff meetings/in-services.
28. Meets standards of behavior expectations.
29. Follows established guidelines for use and/or disclosure of protected health information. Employees should report any breaches of the Health Insurance Portability and Accountability Act (HIPAA) rules to the Privacy Officer immediately. Failure to comply with HIPAA policies and procedures will result in disciplinary action, up to and including termination of employment.
30. Other duties as assigned.

1. High school diploma required or GED required.Some college preferred.
2. Bi-lingual in Spanish/English as follows: Reading - Required. Written - Required. Speaking - Required.
3. Effective organization and communication skills, including neat and legible hand writing/printing.
4. Community health experience preferred.
5. Maintains current CPR certification.
6. Excellent computer skills required.Good working knowledge of Microsoft Office software, especially Word and Excel.
7. Health policies and requirements met (See Personnel Policies).