Post-Acute Care 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 identifies the likely best site-of-care for the patient upon hospital discharge, manages length of stay (LOS) if a Long Term Acute Hospital (LTACH), Skilled Nursing Facility (SNF), Institutional Rehab Facility (IRF) is appropriate, and reduce hospital readmissions. Our program also coordinates the services required for a patient to transition to their home
The Nurse Liaison is an in-market position responsible for identifying and influencing the best site-of-care for the patient upon hospital discharge and manages length of stay (LOS) for Long Term Acute Hospital (LTACH), Skilled Nursing Facility (SNF), and Institutional Rehab Facility (IRF) 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.
Coordinate Post-Acute Care services for the patient and collaborate with Post-Acute Care homecare agencies on PAC plan of care, authorizing services as medically necessary. The Nurse Liaison will document patient interactions and plan of care in the HomeBridge care coordination platform
• Determine the optimal site of care for patients post hospital discharge in collaboration with hospital discharge planners, case managers and hospitalist.
• Manages and influences the transition of assigned Post-Acute Care patients from acute care setting to the SNF, IRF, LTACH or home setting utilizing face to face and/or telephonic outreach to accomplish the goals of the Post-Acute Care Program.
• Coordinate care and facilitate with hospital discharge planners, case managers and hospitalist to obtain Post-Acute Care orders for next site of care.
• Authorize admission and continued stay at SNF, IRF, LTACH and Home Health care using approved medical care guidelines and collaboration with physicians and professionals within the healthcare setting.
• Upon a patient’s discharge to home, facilitates obtaining appropriate home health physician orders for the home care services.
• Contacts referral sources to advise them of referral status. Relays referral status and updates to the appropriate individuals.
• Partners closely with the PAC Medical Director in reviewing discharge plans and length of stay status to ensure optimal outcomes.
• Communicates customer service/provider issues to supervisor for logging and resolution.
• Participates in an annual Inter-rater reliability Testing Process
• Must be willing to travel 75% of the time within assigned geography and occasionally to central CareCentrix locations.
• Typical work schedule is Monday thru Friday 8am to 6pm. Based on business needs, evening and weekend coverage may be needed at times.
Supports the following additional duties as requested:
• Engages and coaches the patient/caregiver assigned using telephonic outreach and standard assessments, patient care plans, and document progress in HomeBridge care coordination platform. Documents all interactions, problems, goals and interventions as well as criteria met ensuring documentation guidelines are maintained.
• Works closely with the Post-Acute Care patient home health agency nurse to facilitate education and adherence to establish health care goals and care plan.
• Identifies patients who meet criteria for other Health Plan programs upon patient graduation from the Post-Acute Care program and communicating patient information to the Health Plan contact(s).
• 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.
• Participates in performance and operational improvement activities.
• Participates in and contributes to ongoing quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested.
• 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.
• Participates in special projects and performs other duties as assigned.
• Typical work schedule is Monday thru Friday 8am to 6pm. Based on business needs, evening and weekend coverage may be needed at times
• Current and unrestricted license for the market (state) of practice as a Registered Nurse.
• Minimum five years of nursing experience (preferably with a geriatric population).
• Expertise in Utilization Management and knowledge of URAC & NCQA standards. Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/case management experience, and governmental home health agency regulations required.
• Excellent negotiation, communication, influencing, problem solving and decision making skills also required.
• Ability to travel frequently to hospitals, SNF, IRF, LTACH and physician practices within the geographic location assigned.
• Candidate will possess excellent communication (verbal/written), organizational and interpersonal skills.
• This position requires high level clinical knowledge, communication, customer service and problem solving skills, as well as, the ability to effectively interact with all levels of management and a highly diverse clientele. Must have strong organizational skills and be able to effectively manage and prioritize tasks.
• Works independently, utilizing sound clinical judgment and critical thinking skills under minimal supervision.
• Must have a strong commitment to quality and standards.
CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.
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.