Home Health Utilization RN – Mount Sinai Health Partners

Job Description



The Mount Sinai Health System

Home Health Utilization RN




Mount Sinai is one of the largest U.S. health systems with a strong reputation for quality of care (18th ranked hospital in the U.S.) and research/education (18th ranked medical school in the U.S.).  We have ~40,000 employees working together to provide billions of dollars in high-quality care each year for millions of patients.


We are accelerating a transition to a business model focused on population health management – our goal is to keep entire communities healthy and out of the hospital.  Mount Sinai Health Partners (MSHP) is the team driving this transformation within Mount Sinai.  The team includes 400+ employees with clinical, contracting, finance, IT, analytics, operations, and product development expertise.


MSHP is a fast growing business unit within Mount Sinai and is looking for team members who:


Are comfortable “playing up” and “playing down” as needed to accomplish business objectives


·         Work productively amidst ambiguity

·         Thrive in fast-paced  work environments

·         Seek to improve the status quo


Within MSHP, Post-acute care team  is responsible for improving the quality of care our patients receive from post-acute care providers and reduce the overall cost of care by transitioning patients safely back to the community.


Role Summary


MSHP seeks a Population Health Clinical Coordinator to assess patient care and coordinate community-based care, monitor patient outcomes and the appropriate/timely discharges back to the community. Responsible to review and evaluate PAC services provided to MSHP population. The Population Health Clinical Coordinator reports to a Nurse Clinical Manager.




·         Uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria for the most appropriate treatment, care or services for patients.

·         Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment.

·         Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

·         Care coordination and facilitation with hospital discharge planners, case managers and hospitalist to obtain Post-Acute orders for engagement and determination for next level of care.

·         Through broad knowledge of clinical care the Home Health Utilization RN evaluates, predicts, and facilitates the trajectory of patient care.

·         Care Coordination and facilitation for community-based home health referrals or linkage to alternative community resources to obtain appropriate care. 

·         Will identify and coordinate appropriate community-based services in lieu of home health, when appropriate.

·         Manages the transition of assigned Post-Acute patients from acute/subacute care setting to the home setting utilizing face to face and/or telephonic outreach to accomplish the goals of the Post-Acute Program.

·         As appropriate, engages the patient/caregiver using tools such as standard assessments, patient care plans, and documents all interactions in the EHP.

·         As needed, the Home Health Utilization RN will also communicate patient plan of care and discharge status with the Primary Care Physician and/or Specialist.

·         Provides clinical expertise and helping to clarify referral source directives and community-based linkage.

·         Participates in performance, operational and quality improvement activities and ensures the collection of data for improvement analysis and prepares reports as requested.

·         May include telephonic outreach to patients to continue coaching patients toward care plan goals.

·         Upon a patient’s discharge to home, may facilitate obtaining appropriate home health physician orders for the home care services or necessary referral to outpatient services and CBOs.




Education and Experience

·         Bachelor of Science in Nursing is required; Masters degree in health related field is preferred.

·         Current and unrestricted RN license for the NY market.

·         Minimum five years of nursing experience.

·         Expertise in Utilization Management.


Additional Skills and Qualities

·         Excellent negotiation, communication, problem solving and decision making skills also required.


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