Clinical Liaison

JOB SUMMARY : The Clinical Liaison develops a strong relationship role with the hospital they serve and the providers including Discharge Planners, Hospitalists, Physicians, and other key clinical referral sources. The Clinical Liaison is responsible for providing ongoing education of our skilled nursing centers and what sets us apart. The intent is to grow referral volume through the delivery of market-leading patient outcomes. ESSENTIAL FUNCTIONS: Maintain relationships with Health Systems and other providers from prescreening for admission to center through post-discharge from center. Prescreening: Meet with potential patients in hospital setting to ensure safe transition into facility as necessary. Review referral to determine patient/resident care needs and coordinate with the managed care/insurance case manager to determine facility plan of care, including determination of level of care and related payment rate from manager care/insurance companies based on clinical condition and needs of the patient/resident. Coordination: Coordinate with IDT on patient/caregiver education. Collaborate with other disciplines in the design, delivery, and outcome of patient/caregiver education programs. Evaluate the progress of the patient/caregiver toward attainment of desired outcomes. Actively lead bedside care conferences Within 24-72 hours of admission Ongoing throughout patient stay Discharge planning Communicate with managed care/insurance company case managers regarding care needs of the patient. Communicate thoroughly and timely with managed care/insurance company case managers for ongoing certification of stay and coordination of care. Present unresolvable IDT concerns to the Director of Nursing/Supervisor. Complete Medication Reconciliation of home medications and OTC and current facility orders in preparation for patient/caregiver education and discharge to home. Oversee and track educational activities to meet the patient’s/caregiver’s identified learning needs. Ensure a bedside care conference occurs within 24 hours of admission to set patient/caregiver goals. Ensure patient/caregiver goals are clear and easily understood. Ensure patient/caregiver education is scheduled, occurring, and patient/caregiver is engaged in education (nutrition, therapy, disease management, medications, activities, treatments, appointments, etc.). Ensure that frequent updates with patient/caregiver on progress toward goals occur and are documented. Ensure the development of a self-administration medication plan while at the facility, if appropriate, for the patient. If not appropriate for the patient, ensure the caregiver receives the education and practice medication administration prior to discharge. Maintain accurate and complete patient/caregiver education records. Ensure documentation of assigned duties and patient caregiver progress of: Education in and out of facility Goals Care planning Bedside care conferences Follow up calls to patient/caregiver after discharge. Ensure post discharge follow ups: Complete first call within 1-3 days post discharge to answer patient/caregiver questions, ensure services and equipment ordered for patient at home arrived and patient/caregiver can access patient personalized web-based information. Complete second call within 12 - 15 days post discharge to answer questions, ensure education is understood and being utilized and verify whether the patient has been to the ER or hospitalized since discharge as determined from patient responses from first call and the patient’s readmission risk factors. Complete third call within 31-33 days post discharge to answer questions, ensures education is understood and being utilized and verifies whether the patient has been to the ER or hospitalized since discharge. Actively serve as a patient advocate. Participate in quality improvement activities and makes recommendations for improvement. Ensure thorough and timely communication with managed care/insurance case managers to coordinate certification and concurrent stay programs. Serve as key communicator of discharge plans related to managed care patients. Review and challenge documentation before sending to MCO. Maximize benefits by coordination of cost-effective care, avoid fragmented care, duplication of services and ensure the appropriate level of care is provided in the most suitable setting. Participate in all Medicare and managed care resident interdisciplinary meetings. Coordinate with team members to ensure discharge-planning goals and objectives are developed and discussed at the interdisciplinary team meetings. Assist with preadmissions evaluation of potential managed care patients, including cost verification, insurance authorization and patient/insurance education as necessary. Communicate with the managed care companies to obtain approval for payment. Assist interdisciplinary team in planning for admission and ensure staff are adequately prepared to meet needs for the managed care/Medicare resident upon admission. Build relationships with case managers at referral sources to aid in seamless transitions of care for patients/residents. Assist nursing staff in communication to physicians, transcription of orders, and documentation as required. Ensure that assigned patient/resident’s care plan accurately reflects appropriate goals, problems, approaches, and revisions based on resident needs. Promote and demonstrate a strong service focus. Perform other duties as assigned within the scope of the position. QUALIFICATIONS: Current state nurse licensure in good standing with the Virginia Department of Health Professions. Post-acute clinical experience preferred. Ability to demonstrate excellent clinical, customer service, communication, and leadership skills. Experience in development of patient/caregiver education Teaching experience preferred. Ability to maintain the highest level of confidentiality to maintain HIPAA compliance. Knowledgeable of and assures compliance with federal and state regulations, company and center policies and procedures. Ability to be flexible, detail-oriented and be able to make effective decisions and work as part of a service excellence team. Case Management and/or Utilization Review experience preferred. Ability to collaborate and coordinate care with interdisciplinary teams. PHYSICAL REQUIREMENTS: Ability to walk, stand or sit for extended periods of time. Ability to travel to different work locations, as needed. Ability to pull up to 20 lbs. Ability to push up to 50 lbs. Ability to lift up to 50 lbs.