Home Care Referrals Coord

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Location: Beverly, MA
Job ID: 178293-1A
Date Posted: Sep 15, 2022
Category: Nursing

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Job Description

Welcome To

Welcome To Beth Israel Lahey Health at Home. Our team provides high-quality home care and hospice services by partnering with physicians, hospitals and skilled nursing facilities to provide specialized care to patients in the comfort of their own home. Our team of nurses, therapists (physical, occupational, and speech), medical social workers, and home health aides work together to devise and implement a compassionate care plan that is expressly tailored for each patient.

About the Job

Position Summary: The Homecare Referrals Coordinator is responsible for the smooth transition of the patient into the home health environment. Receives and coordinates referrals to BILH at Home from affiliated and outside physicians, hospitals, facilities and other community referral sources.



Per-Diem; 8a-6:30p every other weekend (10-20 hours/week)

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.


Essential Duties & Responsibilities including but not limited to:

  • Responds to all requests in a positive manner.
  • Elicits and gathers accurate and pertinent information regarding the patient’s medical, psycho-social and environmental condition to accurately identify critical information needed to initiate the plan of care.
  • Working knowledge of the skills and service provided by each member of the multidisciplinary team and the ability to relate these to identified patient needs
  • Prioritizes referrals based on patient’s home care and hospice needs.
  • Understands and integrates relevant home care and hospice standards, regulations and practices to make decisions regarding appropriateness for care.
  • Accepts and documents verbal orders related to the initiation of services. Inputs initial information into the computer to begin the admission process.
  • Has an understanding of the Medicare, Medicaid, Managed Care environment and works with the Business Office to identify and verify patient’s insurance.
  • Forwards all referral information to the appropriate team for timely initiation of services.
  • Responds to telephone requests for information and interprets services to callers.
  • Uses information technologies including E-Discharge, E-mail, and Epic EMR to process and track referrals and communicate with team members.
  • Develops positive relationships for new and existing referral sources, including physician offices, hospitals and rehab facilities. Collaborates BILH at Home liaisons in outreach efforts.
  • Acts as a resource to referrers, staff, families and patients to develop solutions for excellent patient care.
  • Develops and maintains relationships with referrers through telephonic contact and occasional meetings to ensure quality services.


  1. Communicates with the physician regarding the patient’s needs and obtains/receives physician’s orders as required.
  2. Attends regular agency and team meetings per Exec. Director of Patient Care Services and as needed.
  3. Provides timely communication to Clinical Managers whenever there are unusual requests or complex situations/orders.
  4. Communicates with other disciplines on the care team and community providers to coordinate the care plan (i.e. Insurance case managers, high risk case managers, elder services, protective service, etc).
  5. Practices confidentiality principles set by the agency and federal HIPAA guidelines.


  1. Must have attention to detail when taking, processing and documenting referral requests throughout the intake process.
  2. Proficiency with common office software programs and ability to learn other software products including, but not limited to Epic and E-Discharge.
  3. Completes documentation in accordance with agency timeliness policies.

Professional Development:

  1. Maintains and updates clinical knowledge and skills based on current nursing practice.
  2. Adheres to departmental requirements for required training.
  3. Identifies specific learning needs and goals and collaborates with nursing leadership in developing a plan to meet them.

Additional Duties:

  1. Participates in the weekend/holiday rotation as defined by BILH at Home.
  2. Participates in in-service programs and supervises, teaches and precepts other Homecare Referrals Coordinator personnel per Exec. Director of Patient Care Services.

Organizational Requirements:

  • Maintain strict adherence to the Continuing Care Confidentiality policy.
  • Incorporate Continuing Care Standards of Behavior and Guiding Principles into daily activities.
  • Comply with all BILH at Home and Continuing Care Policies.
  • Comply with behavioral expectations of the Continuing Care Division.
  • Maintain courteous and effective interactions with colleagues and patients (internal and external customers)..
  • Demonstrate an understanding of the job description, performance expectations, and competency assessment.
  • Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
  • Participate in departmental and/or interdepartmental quality improvement activities. 
  • Participate in and successfully completes Mandatory Education.
  • Perform all other duties as needed or directed to meet the needs of the department.



  • Professional Nurse from a Graduate of National League for Nursing accredited school of nursing.

Licensure, Certification & Registration:

  • Registered Nurse license strongly preferred.


  • 1-2 years’ experience in Home Health Care.

Skills, Knowledge & Abilities:

  • Comprehensive knowledge of home health care.
  • Demonstrates excellent observation and problem solving/critical thinking skills.
  • Well-developed verbal and written communication skills; essential computer skills to work with EMR.
  • Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.
  • Self-directed and able to work with minimal supervision.
  • Shows strong ability to organize and prioritize workload independently.