What are the responsibilities and job description for the Nurse Liaison - Post Acute Care (Remote- Monmouth, NJ Sign on Bonus! position at CareCentrix?
Are you an experienced Registered Nurse with a passion for shaping the future of healthcare?
As a Nurse Liaison you will be an expert in resource management, a master of utilization review and a compassionate partner for patients and their support network. You will be responsible for an assigned caseload at acute and post-acute care facilities. You will conduct in person, on site, face to face outreach, with patients to introduce the Post-Acute program. You will gather patient demographics and collaborate with hospital clinicians, patients and their family to develop a discharge plan of care and 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.
The Post-Acute Care program helps to reduce hospital readmissions of patients and has aspects of education and coaching to assist patient's transition home after a hospital stay. The program works directly with patient treatment plans, facilitates in home health care services to accomplish the treatment plan, patient goals and patient education/coaching along with adherence/compliance monitoring.
Responsibilities
In this Job, you will:
- Determine the optimal site of care for patients post hospital discharge in collaboration with hospital discharge planners, case managers and hospitalist.
- Manage and influence 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.
- Facilitate home health physician orders for home care upon a patient's discharge to home.
- Contact referral sources to advise and relay updates to the appropriate individuals.
- Partner closely with the PAC Medical Director in reviewing discharge plans and length of stay status to ensure optimal outcomes.
- Communicate customer service/provider issues to supervisor for logging and resolution.
- Engage and coach the patients/caregivers for performing standard assessments, patient care plans, and document progress in the HomeBridge platform.
Document all interactions, problems, goals and interventions to meet documentation guidelines. - Work closely with the home health agency nurse to facilitate education and adherence to establish health care goals and care plan.
- Act as a clinical resource for unlicensed staff, to provide clinical expertise and help with referral source directives, clinical questions and issues.
- Participate and contribute to ongoing quality assessment/improvement activities, performance, data collection, analysis, operational process activities and prepares reports.
- Assist team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
- Participate in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
- Participate in special projects and perform other duties as assigned.
This is the job for you if:
- You are willing to travel daily to assigned facilities to hospitals, SNF, IRF, LTACH and physician offices within assigned geography locations.
- You can work independently, utilizing sound clinical judgment and critical thinking skills under minimal supervision.
- You have a strong commitment to quality and standards.