RN Navigator: Home Health & Care Transitions

LiveWell Homecare Agency, LLC; Lancaster (TX); On-site; USD 85,000 - 110,000; Full time

Job summary

LiveWell Homecare Agency, LLC is seeking an RN Navigator Home Health Review to monitor CMS criteria for continued home health services. The role acts as a patient advocate, coordinating with PCPs, specialists, and community providers to facilitate smooth care transitions.

Responsibilities include evaluating Home Health 485 forms, leading case conferences, recommending care adjustments, coordinating among agencies and patients, supporting transitions of care, and leveraging EMR tools to track

Qualifications

• Bachelor’s Degree in Nursing required or preferred.
• Active RN license in the state of employment or compact license.
• 3–5 years of clinical experience, home health or care management preferred.
• Strong knowledge of CMS and payer guidelines; proficiency with EMR systems.

Responsibilities

• Evaluate and interpret Home Health 485 forms based on medical necessity and CMS guidelines.
• Facilitate case conferences to assess patient progress and develop discharge or recertification plans.
• Recommend appropriate care adjustments to PCPs based on assessments and guidelines.
• Coordinate communication among home health agencies, providers, and patients to ensure needs are met.
• Support transitions of care, including medication reconciliation, patient education, and follow-up planning.
• Utilize electronic medical records and care management tools effectively.
• Monitor program success metrics and identify improvement opportunities.
• Promote a caring and responsive work environment by understanding patient and team needs.

Skills

RN

Care coordination

CMS guidelines knowledge

EMR proficiency

Education

Bachelor's degree in Nursing

Tools

Electronic Medical Records (EMR)

Job description

LiveWell Homecare Agency, LLC is seeking an RN Navigator Home Health Review to monitor CMS criteria for continued home health services. The role acts as a patient advocate, coordinating with PCPs, specialists, and community providers to facilitate smooth care transitions.

Responsibilities include evaluating Home Health 485 forms, leading case conferences, recommending care adjustments, coordinating among agencies and patients, supporting transitions of care, and leveraging EMR tools to track