LPN Patient Transition Nurse Coordinator, Home Health, Full-time

About Brooks Rehabilitation 

For more than 50 years, the nonprofit Brooks Rehabilitation, headquartered in Jacksonville, Fla., has been a comprehensive system of care for physical rehabilitation.

Named by Newsweek as the number one  Physical Rehabilitation Center in Fla., Brooks operates two inpatient rehabilitation hospitals, including the nation’s largest with 170 beds; one of the region’s largest home healthcare agencies; more than 40 outpatient therapy clinics; the Brooks Rehabilitation Medical Group; two skilled nursing facilities; assisted living; memory care; and a Center for Inpatient Rehabilitation in partnership with Halifax Health (Daytona Beach).

Brooks operates the Clinical Research Center, which specializes in advanced research to further the science of rehabilitation.

Brooks also provides many low- or no-cost community programs and services to improve the quality of life for people living with physical disabilities.

For more information, visit BrooksRehab.org. 

 

Location Overview: 6676 Corporate Center Parkway (BRHH Jacksonville home office) 

Position Summary: The Patient Transition Nurse Coordinator within the Central Intake Department serves as a vital clinical resource responsible for evaluating, coordinating, and facilitating appropriate patient transitions into Home Health services.

This nurse collaborates with referral sources, physicians, case managers, and patients to ensure accurate clinical assessments, determine the appropriate level of care, and coordinate a seamless admission process for services for Home Health programs. 

Job Responsibilities:  


* Serve as the clinical liaison within the Central Intake team to review incoming referrals for medical necessity, clinical appropriateness, and admission criteria. 



* Collaborate with referral sources, physician offices, and case managers, to gather necessary clinical documentation and ensure a seamless transition into care. 



* Review orders to determine eligibility and the appropriate level of care for Home Health 



* Ensure all orders are complete and include all necessary MD orders for the care of the patient 



* Assist in the verification of insurance benefits and authorization requirements, ensuring all necessary approvals are obtained prior to admission. 



* Coordinate closely with operational teams to schedule admissions, ensuring timeliness and continuity of care. 



* Participate in daily intake huddles to support the team in meeting patient needs and organizational capacity goals. 



* Maintain thorough and accurate documentation within the intake system, ensuring compliance with regulatory and organizational standards. 



* Act as a clinical resource for the intake team, providing guidance on eligibility criteria and complex cases. 



* Assist team with PDGM dx identification 



* Helps gather all needed information for referral, clinical notes, MD order and F2F documentation 
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