Accountable for the coordination of the patient's clinical services between hospital setting and the home setting. Promotes, educates and coordinates services when the patient is transferred from the hospital to care transitions, home healthcare or hospice services. ? What you will do. Serves as home care expert and resource to referral sources and/or agency staff regarding patient care, treatments and services that can be provided in the home/hospice setting including skilled and nonskilled services or other programs. Provides clinical assessment and assists referral sources with identification of appropriate services in the post-acute home care setting including education regarding admission criteria. Obtains physician orders, face to face, for home care/hospice services prior to each patient’s admission to home care. Coordinates the home care/hospice plan as ordered by the physician. Clinical excellence and ability to proactively determine actual and potential complications in the home setting of care delivery for success of the patient. Documents each patient’s home care plan and coordination activities according to standards established by Avera. Facilitates communication between entities and assigned hospital/agency staff, identifying and reporting processes in the system where communication and/or continuity of care can be improved. Maintains knowledge of Federal and State regulations as well as Agency policies and procedures. Essential Qualifications. The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer. Required Education, License/ Certification, or Work Experience:Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire Preferred Education, License/ Certification, or Work Experience:1-3 years home health/hospice related experience