Registered Nurse Liaison RN

1 week ago


Buffalo NY, United States Ubiquity Full time

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.
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.Partner closely with the PAC Medical Director in reviewing discharge plans and length of stay status to ensure optimal outcomes.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 75% of the time 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.
You have a broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/case management experience, and governmental home health agency regulations. (You are willing to travel 75% of the time to hospitals, SNF, IRF, LTACH, and physician offices within assigned geography locations.
Full range of benefits including Health, Dental, and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training, and more.Advancement opportunities, professional skills training, and tuition ReimbursementGreat culture with a sense of community.


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