[Hiring] Home Health Transitional Care Liaison @Residential Home Health and Residential Hospice

Role Description

• Responsible for obtaining complete/accurate demographic information, medical history including diagnosis for care and primary care physician information.
• Introduce Residential Home Health to the patient/caregiver, explaining the scope of services, skilled services requested, and coordinating start of care visit.
• Order requested DME, infusion services, and wound care.
• Conduct community education as requested by sales to physician offices and assisted living facilities, including educational in-services, blood pressure clinics, and health fairs.
• Provide patient education at bedside, arrange post-discharge physician follow-up appointments, and share important discharge information with the primary care physician.
• Attend discharge planning meetings as requested, working with the facility team to ensure a safe and successful discharge home.
• Determine appropriateness of skilled home care services/hospice.
• Conduct one (1) week follow-up customer service call to patient/caregiver when necessary.
• Communicate with the Clinical team on all complex, chronically ill patients, assisting staff and referral sources in preventing re-hospitalizations.
• Complete documentation about patient status and discharge plan with Residential’s EMR to facilitate communication and complete documentation within partner EMR when applicable.
• Assist in obtaining regulatory documentation as required.
• Perform all other duties as assigned by supervisor.

Qualifications

• Demonstrates high skill set to work with varied groups and departments within the organization and with partners.
• Displays a high level of professionalism by exercising appropriate communication, patience, flexibility, and a cooperative attitude.
• Able to provide excellent customer service.
• Effectively manages concurrent demands and multi-tasks to completion during the assigned shift.
• Detail-oriented to manage complex situations and meet regulatory requirements.
• Maintains a consistent professional attitude with referral partners and patients.

Requirements

• Associate Degree required, Bachelor Degree preferred.
• One (1) year of experience in home health preferred.
• Minimum of one (1) year of experience in an acute care setting.
• Minimum of five (5) years of experience in a customer service capacity.
• Must have and maintain in good standing professional license, certificate, or registration.

Physical Demands

• Regularly required to talk or hear.
• Regularly required to stand, walk, sit, climb stairs, use hands to handle or feel objects, tools, or controls; and reach with hands and arms.
• Frequently lifts and/or moves up to 20 pounds.
• Specific vision abilities required include close vision and the ability to adjust focus.

Work Environment

• Employee travels by automobile and is exposed to changing weather conditions.
• Required to drive daily for meetings and/or visits to residential homes.
• Works in varied residential environments based on assigned caseload.