RN Coordinator-Home Care-Weekends

Duke Health; Durham (NC); On-site; USD 65,000 - 90,000; Full time

Job summary

Duke HomeCare & Hospice in Durham, NC seeks a skilled RN Coordinator to support home health, hospice, and infusion services. This role focuses on coordinating patient referrals at Duke University Hospital on weekends, with weekday support across hospitals as needed.

The ideal candidate educates patients and families, collaborates with interdisciplinary teams, and ensures seamless transitions of care. Strong nursing experience and regulatory knowledge are essential.

Qualifications

• BSN required and NC RN licensure (or compact licensure)
• BLS required, may be renewed during orientation
• Three years of nursing experience required

Responsibilities

• Assess home care needs and determine patient suitability for home care services.
• Educate patients and families on home care and infusion services.
• Coordinate with Case Manager and physician teams to develop discharge plans.
• Monitor patient referrals and ensure appropriate services are provided until discharge.
• Document activity in Maestro, CareTend, and other systems.
• Engage with referral sources to identify gaps and opportunities for process improvement.
• Understand insurance benefits and reimbursement guidelines affecting home care services.
• Maintain knowledge of regulatory guidelines related to home care.
• Stay informed about services and products available through DHCH.
• Collaborate with referral center and finance to complete necessary documentation to prevent insurance denials.
• Build positive relationships with internal and external customers.
• May include site-specific duties and after-hours coverage.
• Perform other related duties as needed.

Skills

Care coordination

Communication

Documentation

Interdisciplinary collaboration

Patient education

Relationship building

Education

BSN

RN licensure (NC or compact)

BLS certification

Tools

Maestro

CareTend

Job description

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke HomeCare & Hospice

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

Schedule: Ten-hour shifts (8 AM to 6:30 PM), Friday, Saturday, Sunday, Monday

The RN Coordinator is a dynamic, fast-paced role supporting home health, hospice, and infusion services. The primary focus is coordinating patient referrals at Duke University Hospital on weekends, with opportunities to support all three hospitals during weekday shifts.

This role assesses home care needs, educates patients and caregivers on safe and effective home health and hospice services and infusion devices, and partners closely with interdisciplinary teams, referral sources, and community providers to ensure seamless, high-quality transitions of care.

The ideal candidate thrives in complex care environments, builds strong relationships across disciplines, and is passionate about connecting patients and families to the services they need at home.

MAJOR JOB RESPONSIBILITIES

Clinical Care Coordination

• 1. Utilize comprehensive assessment skills to determine a patient’s appropriateness for home care, initiate the appropriate home program referral, and provide patient/family education related to the initiation of home care services.
• 2. During patient/family education, identify any barriers or concerns related to home care by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Communicate the identified concerns to the Case Manager or physician team to develop a comprehensive discharge plan.
• 3. Provide ongoing daily assessment and monitoring of patient referrals until discharge to ensure all patients have the appropriate services, including ongoing home support. Coordinate with the hospital Case Manager to request additional services/orders.
• 4. Maintain effective communication with the health care team related to assessment findings, additional discharge planning needs, and during patient/family education.
• 5. Electronically document all activity in Maestro and CareTend and other documentation systems relevant to the position.
• 6. Meet with referral sources regularly to identify gaps in care, patient population needs, opportunities for referral process improvement, and ongoing identification of additional patient/staff educational opportunities.
• 7. Maintain a working knowledge of specific insurance benefits, reimbursement guidelines, and maintain an understanding of their impact on the delivery of home health, hospice, and infusion services.
• 8. Maintain a working knowledge of applicable federal and state regulatory guidelines related to home care services
• 9. Maintain a current knowledge base of the comprehensive services, products, and supplies available through DHCH.
• 10. Work with DHCH referral center, finance, and the appropriate home program to accurately complete and obtain any additional required documentation to facilitate the prevention of an insurance denial for services.
• 11. Develop and maintain a positive relationship with internal and external customers.
• 12. Job responsibilities may include site-specific duties, weekend/holiday or after-hours coverage as designated at each entity.
• 13. Perform other related duties incidental to the work described herein.

Education and Certification:

BSN required. Current RN licensure in the state of North Carolina,or compact licensure in participating stateis required.

BLS required, may be renewed during orientation.

Work Experience:

Three years of nursing experience are required.

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions:

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.