Fairview Health Services Clinical Coordinator-Home Care in St. Paul, Minnesota


Work with referral sources; check/verify initial payer information to begin service or to determine if no payer for home care patient services. Effectively interact with referral sources, patients/patient family. Elicit pertinent clinical and social data related to the referral as well as determine need for service(s). Document and communicate information for staffing and field clinicians. Utilize home care EMR to enter and maintain patient, physician, clinical, and financial coverage information. Utilize clinical background to own and work the referral to provide a clinical picture for each referral. Acts as a liaison between staff and physicians to facilitate coordination of care to HEHC clients.


  • Acts as a liaison between staff and physicians to facilitate coordination of care to HEHC clients: coordinates Infusion (IV) and enteral referrals with home equipment companies

  • Acts as a resource to clients/caregivers and field clinicians on clinical direction, issues, patient concerns, and problem solving

  • Resource person for KCI on monthly documentation requirements and care coordination

  • Resource for care coordination for PACCT referrals

  • Ensure timely entering of High Risk and At Risk referrals

  • Serves as a resource to the referral sources, staff, and physicians regarding HealthEast Home Care services

  • Provides Clinical support to field staff

  • Communicates effectively and timely with interdisciplinary team members and patients

  • Clinical resource for questions about diagnosis, procedures or equipment

  • Assists Patient Service Coordinators in the triaging of visits, putting client safety first in all decisions

  • Makes clinical decisions on issues relating to staffing, and assists with completion of escalation each day

  • Works with the Clinical Manager (or other appropriate, designated resource) to facilitate process for Transferring of Referrals to partner agencies

  • Resolve patient issues or immediate concerns and complete all appropriate documentation

  • Reports issues to Clinical Manager or Director as needed

  • Triage calls from patient or caregiver

  • Manages Triage calls from patient &/or caregiver and resolves on phone or initiate SNV as needed

  • Completes timely documentation and notification to Case Manager

  • Assist Clinical Staff in timely completing of KCI clinical documentation and ordering of supplies

  • Resource person for KCI on monthly documentation requirements and care coordination

  • Work with referral sources and patients to communicate and document patient needs for any services

  • Places initial phone call to patient (or their caregiver) referred by their provider for home care to

  • Discuss HEHC service concept

  • Determine if they are interested in receiving services

  • Work with patient’s family to advance services

  • Confirm demographics, address, and attending physician

  • Check to see if they know how to do treatments/take meds until the clinician comes to visit

  • Inform patient what will occur on the first visit, i.e. med check, insurance card verification, etc

  • Keeps patients informed of patient flow delays

  • Enters appropriate documentation in EMR

  • Takes telephone orders from MD’s

  • Completes electronic notes for referral information and referral data

  • Enters and generates initial orders per protocol

  • Clearly communicate and align patient needs for home care, care management, triage nurse and care coordination

  • Call referral source, physician, and patient/family/caregiver to communicate appropriate services/disciplines/orders needed for timely initial visit

  • Determines episode type for resumption of care, continuation of care or the need to complete a new episode

  • Consults with SpecialistPatient Service Coordinators regarding creation of new episodes or unlocking of old episodes for on-going documentation

  • Respond to communication sent to or received from case managers relating to needs for a new episode due to change in payer coverage, coverage under a different payer requiring OASIS, etc

  • Inquire about and resolve customer satisfaction

  • Follow up until the concern is resolved

  • Report concerns and follow through to the appropriate manager(s)

  • Exhibit excellent customer service with clients, co-workers, referral sources and internal customers

  • Include Liaisons when customer service follow up is necessary

  • Role includes being part of a team of Nurses who provide back up to Weekend Supervisor, including weekends and holidays

  • Maintains knowledge of, and complies with, all relevant laws, regulations, policies, procedures and standards

  • Actively participates in creating and implementing improvements

  • Performs other responsibilities as needed/assigned


  • Bachelor's degree required

  • Bachelor's degree in Nursing or Physical Therapy

  • Either RN or PT required

  • Registered Nurse MN (RN) through MN Board of Nursing

  • License Physical Therapist (PT) throughMN Board of Physical Therapy

  • 1 year recent RN experience in home care working directly with patients required

  • Previous customer service experience required

  • Keyboarding, MS Word and email experience required

  • Knowledge of home care coverage insurance guidelines preferred

  • Internal HealthEast Home Care experience preferred

About HealthEast

At HealthEast, our patients are our neighbors and we are dedicated to their, and our, optimal health and well-being. We are guided by our faith-based heritage, a call to healing that respects the dignity and culture of every person. We empower our patients with user-friendly access to their health information, dependable service, and affordable, high-quality care.

We put new, more efficient models of care into practice, allowing our 7,500 employees and 850 physicians to focus on what’s important: providing compassionate health care that puts the patient and their needs first. With 14 clinics, home care, a medical transportation center, and four hospitals — Bethesda Hospital, St. John’s Hospital, St. Joseph’s Hospital, and Woodwinds Health Campus — we provide excellent family health and specialization, including primary, maternity, orthopaedics and post-acute care.

Job ID 2018-10581

Category Nursing

Contract Status ND

FTE 0.60

Shift Days

HealthEast is an Equal Opportunity Employer. HealthEast will not discriminate in public accommodation, or employment on the basis of race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, membership or activity in a local commission, disability, sexual orientation, gender identity or expression, age or genetic information.