Transitional Care Liaison-HHH

It's fun to work in a company where people truly BELIEVE in what they're doing!

Our intention is to have employees who are passionate about making their personal mission statement come to life each day at work!  Be it through providing healing, eradicating loneliness, contributing to efficiencies, streamlining processes, being dependable, sparking creativity or something else, the demonstration of HOW you do your job is just as important as WHAT you do in your job.

Alongside our valued employees, we are making a difference throughout the state of Ohio in the lives of those that need healthcare or those embracing the next chapter of their lives. Sustained members of our team demonstrate accountable behavior and share our values of customer service, innovation, integrity, inclusion, financial stewardship, leadership and care.

The Transitional Care Liaison is an integral member of the health care team in representing the organization to the greater community of health care providers by marketing the agency services to influencers using a strategic marketing plan for the purpose of generating consistent admissions from physicians, hospitals, and post-acute care providers to maintain a census level and payer mix at or above budget.

Essential Activities and Tasks 

Community and Provider Relations - 45%

• Develop relationships with case managers, social workers and discharge planners to generate and facilitate new referrals.

• Meet with patients and/or families to evaluate their need for home health and hospice services.

• Obtain pertinent demographic and medical information for writing up referrals so that appropriate care can be initiated upon patient discharge.

• Communicate with hospital staff when the organization’s patients return to the hospital, either through the ER or for planned admissions to obtain a resumption of care when they are discharged.

• Communicate with clinical staff/team managers at our agency about patient admissions, expected discharge dates, and any other problems or concerns related to our ability to care for the patient.

• Meet with patients and families in the hospital setting to explain the organization’s services after receiving permission from hospital to follow patient.

• Discuss agency hospice and private duty services with potential referrals and write up referrals as necessary.

Communication - 35%

• Communicate with key hospital staff when Accountable Care Organization (ACO) beneficiaries are admitted to the hospital to obtain orders for home health care, hospice, or Home to Stay.

• Communicate with office clinical staff and team members regarding ACO patient admissions, expected discharge dates and other problems or concerns related to our ability to care for the patient.

• Communicate with ACO beneficiaries’ primary care physician offices to obtain timely physician appointments following post hospital discharge.

Quality and Compliance Management - 20%

• Understand and easily access the company’s EMR, as well as other EMR computer systems in multiple healthcare facilities.

• Review patient medical information and write up referrals so that appropriate care can be initiated upon patient discharge.

• Secure appropriate face to face documentation from discharging physician.

All other duties as assigned.

Qualifications

Education

• Bachelor’s degree in business, marketing or nursing required; or

• Current unencumbered license for the state of Ohio to practice as a Registered Nurse (RN), Licensed Practical Nurse (LPN) required.

Experience

• Five years experience in nursing required.

• Two years experience in a hospital setting required.

• Strong knowledge of the full continuum of care and the eligibility requirements for home health, hospice, skilled nursing, and assisted living required.

• Proficiency with Windows, Microsoft Office (Word, Excel, PowerPoint), and the internet required.

Other Requirements

• Must be able to read, write, speak, and understand the English language.

• Must possess a valid driver's license and acceptable driving record. Must be insurable under professional liability and crime coverage policies as specified by insurance carrier underwriting standards.

Working Conditions and Special Requirements

• Sitting - Up to 8 hours/day

• Standing - Up to 4 hours/day

• Walking - Up to 6 hours/day

• Lifting, transferring, pushing or pulling residents/patients or equipment/supplies - Up to 50 pounds

• Driving - Up to 4 hours/day

• Work weekends, evenings, and holidays. - As needed for coverage

• Subject to residents/patients with various disease processes - Occasional

• May be exposed to infectious waste, disease, conditions, etc. including exposure to the AIDS and Hepatitis B viruses - Work day

• Risk Category for Exposure to Bloodborne Diseases - II