The Nurse Liaison is responsible for identifying and influencing the best site-of-care for the patient upon hospital discharge and manages length of stay for Long Term Acute Hospital, Skilled Nursing Facility, Institutional Rehab Facility for their assigned acute and post-acute care facilities. The Nurse Liaison will collaborate with facility discharge planners, patient and family to develop a discharge path of care. The Nurse Liaison will participate in Care plan meetings and meet with patients as appropriate. In addition, the Nurse Liaison will conduct in person, on site initial face to face outreach with patients to introduce the Post-Acute Care program.
• Manages the transition of assigned Post Acute patients from acute care setting to the skilled nursing facility and/or home setting utilizing face to face and/or telephonic outreach to accomplish the goals of the Post Acute Program. Care coordination and facilitation with hospital discharge planners, case managers and hospitalist to obtain Post Acute orders for engagement.
• In partnership with the UM team, authorize admission and continued stay at Skilled Nursing Facilities and Home Health care using approved medical care guidelines and collaboration with physicians and professionals within the healthcare setting.
• As appropriate, engages the patient/caregiver using tools such as standard assessments, patient care plans, and documents all interactions in the Homebridge care coordination platform.
• As needed, the Nurse Liaison will also communicate patient plan of care and discharge status with the Primary Care Physician and/or Specialist.
• Facilitates obtaining appropriate home health physician orders for the home care services when needed.
• Acts as a clinical resource for unlicensed Post Acute Care Coordinators, providing clinical expertise and helping to clarify referral source directives. Receives/responds to requests from unlicensed staff regarding scripted clinical questions and issues.
• When needed, contacts referral sources to advise them of referral status.
• Participates in performance, operational and quality improvement activities and ensures the collection of data for improvement analysis and prepares reports as requested.
• Communicates customer service/provider issues to supervisor for logging and resolution.
• Assists team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
• Participates in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
• Must be willing to travel to acute and post-acute care facilities within the Candidates local assigned geographic area of New Haven, Fairfield, and New London Counties 25% to 50%.
• Typical work schedule is Monday thru Friday 8am to 6pm. Based on business needs, evening and weekend coverage may be needed at times.
CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law