Clinical Nurse Liaison- PT

Clinical Nurse Liaison- PT Days at Hebrew Senior Life summary:

The Community Clinical Liaison generates referrals and coordinates care transitions to home health and hospice services by building relationships with hospitals, post-acute facilities, physician practices, assisted living communities and internal teams. Responsibilities include patient screening, tracking census and PINGs, intake coordination, patient/family education, marketing HCBS services, and maintaining documentation in care systems. The role requires clinical/community-based healthcare experience, strong communication and relationship-building skills, computer literacy, and typically a clinical license and healthcare sales experience are preferred.

Job Description:

Position Summary:

The Community Clinical Liaison performs a key role in the generation of referrals to HSL Home and Community Based Services with primary focus on Home Health and Hospice referral generation.

This role serves as the entry point for patients into home-based services and has direct impact on the evolving needs of the elders served and the satisfaction of the patient and their family and caregivers with the services provided.

The Community Clinical Liaison is responsible for initiating and establishing relationships that result in referrals from hospitals, post-acute facilities, physician practices and assisted living communities by ensuring coordination of care transitions to HSL Home Care and Hospice.

The Community Clinical Liaison enhances continuity of patient care by providing liaison between assigned locations (SNFs, RSUs ALs and other), physicians, and home care agency.

The Community Clinical Liaison screens patients at hospitals and SNFs that are referred to HSL Home Care and Hospice.

The Community Clinical Liaison serves as community educator by attending networking events and vendor fairs and serving as a resource about supportive services available in the home.

Position Responsibilities Include:

• Transfers Patients from facility to HCBS service lines that include home health and hospice services by establishing and maintaining relationships with nurses, case managers, social services, physical and occupational therapy, and other support services.

• Provide clinical liaison services to the Rehabilitation Services Unit (RSU) at both the Hebrew Rehab Center and New Bridge. These services will be provided primarily via e-mail and telephone but may be via virtual conference and in person as needed.

• Track patient census on RSUs and communicate to case managers all potential referrals to HSL Home Care based on patient care needs, care address, and insurance.

• Review Patient PING and update home care staff when a current patient is hospitalized and transferred to a rehabilitation facility; act on and resolve PINGS.

• Update Home Care Hospitalized Patient List with information obtained from PING, housing sites, home care staff and discharge planners.

• Provides all necessary information concerning home care/hospice intake coordination and provides input related to clinical concerns for individual patients.

• Resolves patient care issues by working one-on-one with Patient Care Managers to standardize patient home care assessments; collecting relevant information; conferring with co-care givers; assessing patient home care needs in person, telephonically or remotely as warranted.

• Keeps facility and attending physician informed of patient status by monitoring and reporting home care services rendered and/or modified; following up on patient reports and other patient information; anticipates additional home care services needed, i.e. wound therapy, physical therapy, social work and/or other specialties.

• Promotes effective written/verbal communication daily.

• Gives accurate information to patients and or families regarding home care and related issues.

• Serves and protects home care/hospice by adhering to professional standards, policies and procedures, federal, state, and local requirements, and professional and licensing standards.

• Promotes education for patients, their families and the community.

• Assists in intake process by entering as much documentation as possible regarding patients transfer to home care/hospice

• Functions as a member of the Intake team as requested.

• Updates job knowledge by participating in educational opportunities.

• Serves as a resource and support to patients.

• Identifies and responds to safety concerns of patients.

• Maintains compliance with policies, procedures, and regulatory matters.

• Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies.

• Participates in personal and professional growth and development including staff meetings and in-service education.

• Communicates with patients, families, and other health professionals in a manner that conveys respect, caring, and sensitivity.

• Contributes to HCBS program effectiveness by identifying short-term and long-range issues that must be addressed; providing information and…