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.

Location: Duke Raleigh Hospital

Make a meaningful impact where hospital care meets the home.

The Care Coordinator is a dynamic role focused on coordinating home health, hospice, and infusion services for patients at Duke Raleigh Hospital. This position assesses inpatients home care needs, provides education to patients and caregivers, and helps ensure they are prepared to safely manage care at home, including hospice, home health, and infusion therapies.

Working closely with interdisciplinary teams, referral sources, and community partners, the Care Coordinator plays a key role in creating seamless, high-quality transitions from hospital to home.

Work Schedule & Staffing Coverage

The standard work schedule is Monday through Friday, 8:30 AM to 5 PM.

On-Call Responsibilities

Employees participate in an on-call rotation every 4–6 weeks to provide weekend coverage when weekend staff is on PTO, ensuring continuity of operations.

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, Degrees and Formal Training

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

BLS required, but if not current 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.