Do you want to make a difference and help patients heal and age at home? As the Nurse Liaison you will be responsible for an assigned caseload at acute and post-acute care facilities. You will conduct in person, on site initial face to face outreach with patients to introduce the Post-Acute program, gather patient demographics and collaborate with hospital clinicians, patient and family to develop a discharge path of care. You will coordinate post-acute care services for the patient and collaborate with Post-Acute homecare agencies on post-acute care plan of care, authorizing services as medically necessary.
Post-Acute Care (PAC) Program is an end-to-end post-acute offering that manages up to 90-day episodes of care, beginning prior to the patient's discharge from the hospital, or for elective surgical cases, outreach begins prior to hospitalization. The program optimizes our home-based network, identifies the likely best site-of-care for the patient, manages length of stay (LOS) if a Skilled Nursing Facility (SNF) is appropriate, and reduces hospital readmissions. Our program also coordinates all of the services required for a patient to transition to their home faster and safer, via our network of home health, durable medical equipment and home infusion providers, all of whom are supported by our CareCentrix care coordination team.