As the Nurse Liaison you will be part of a great team helping to shape the future of healthcare. 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. The Nurse Liaison 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.
• 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.
• May include telephonic outreach to patients to continue coaching patients toward care plan goals.
• Upon a patient’s discharge to home, may facilitate obtaining appropriate home health physician orders for the home care services.
• May include contacting referral sources to advise them of referral status. Relays referral status and updates to the appropriate individuals.
• Participates in special projects and performs other duties as assigned.
We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.