Care Transition Liaison

Tufts Medicine•Malden, MA

2d•$72,372 - $90,465•Hybrid

About The Position

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Nursing Support duties: Provides basic care services to patients, but does not have an RN or LPN license. Positions in this nursing support work under the direction of physicians, mid-level practitioners, and may work under the direction of registered nurses depending on their unit. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience. Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices. This role is responsible for generating home health and hospice referrals in designated territory/facility while serving as liaison between the agency, hospitals, nursing homes, physicians, patients and families, and community organizations. The Care Transition Liaison works to thoroughly identify the needs of referral sources, demonstrating a clear understanding of how referral sources make decisions and identifying decision-makers. Collaborating in a cross functional environment, assists with programs and protocols that provide for the delivery of improved home health care services, including performing complete and thorough pre-intake screens as appropriate.

Requirements

Bachelor's Degree
Valid state issued Driver’s License.
Two (2) years of experience marketing to physicians, long-term care, and assisted living facilities to develop effective relationships and referrals.
If hired prior to 9/28/2026, CPR Certification is required upon hire. If hired after 9/28/2026, BLS Certification is required within thirty (30) days of hire.

Nice To Haves

Massachusetts RN Licensure.

Responsibilities

Increases census through marketing of geographically defined areas and develop specific referrer relationships with potential referrers.
Develops specific referrer relationships with hospitals/community in defined geographic areas with primary focus on case management departments or as determined by the marketing team.
Provides referring agencies with information on existing and new programs and services by arranging presentations to hospitals and personnel as per marketing plans developed by the marketing team.
Schedules educational programs at hospitals in geographically defined areas to be given by Liaison, Program Coordinators, or other HHF staff as appropriate.
Notifies referring agencies/personnel of patient’s progress at HHF as appropriate. Delivers/mail all discharge summaries to social workers and discharge planners in defined territory.
Achieves business development targets such as conversation ratio of referral to SOC, hospital admission targets, and contacts/evaluations through detailed marketing plans. Supplies data for statistical reports and Assesses implications of data collection and participates in strategic planning.
Seeks out opportunities to become a preferred provider or partner for the account rather than solely a vendor.
Maintains an on-going, intimate knowledge of all HHF products lines and services and promote them as appropriate with the account.
Seeks out opportunities to participate or attend in account’s meetings, task forces, clinical teams, etc. where HHF expertise in post-acute care would benefit the account (i.e. ACO committees, re-admission groups, leakage management efforts) and would provide HHF a way to strengthen the relationship with the account. Identifies circumstances where it would be appropriate/expected to involve participants representing HHF’s clinical departments in order to add particular expertise or leadership.
Understands the competitive landscape in general and the individual competitors for each assigned account.
Completes pre-admission screening process and facilitates home assessment as per policy and presents to intake office to facilitate timely and appropriate SOC.
Utilizes assessment skills to complete thorough screening of patient’s referral to HHF as demonstrated by the recognition and documentation of patient’s medical stability, rehab potential, rehab tolerance and applicability to accepted standards of HHF.
Contacts referring agencies, physicians and families as appropriate with decision of Admissions and decision of insurance companies.
Autonomously makes decisions on straight forward assessments at time of screening. Provides case managers with decisions at time of screenings.
Participates in broad based referral development activities of Liaison team to ensure information sharing and facilitate efforts of entire Liaison Team.
Provides regular feedback to manager/director on referral development in defined territories.
Consistently communicates with and offers assistance when available to team members in neighboring territories.
Consistently attends liaison marketing meetings and generates creative ideas and presents them at marketing meetings.
Completes referrals in territories outside of primary territory at request of intake, liaison manager and colleagues.
Participates in daily operation of Referral Department to assure smooth referral coordination.
Assists intake office in discussing details of the case or in obtaining important information.
Coordinates admissions and patient flow effectively with intake office and care providers. Keeps all parties informed.
Identifies and consistently meets with insurance contacts in each account. Understands the insurer- specific requirements and orientation to HHF.
Obtains insurance information on potential patients and forwards appropriately to facilitate prompt insurance verification and speed admission process while assuring pre-certification (if required) will be obtained before admission.
Meets face to face with families and patients to promote HHF and to facilitate the patient/family decision process for services.
Communicates effectively and maintains an engaged relationship with account case managers and discharge planners.
Reports corporate compliance concerns to the CEO or Chief Compliance Officer when applicable.
Acts autonomously when gathering referrals in other facilities.
Serves as the link between the account and HHF care providers. Effectively works to prevent problems and resolves issues if they happen.
Actively pursues educational opportunities and shares knowledge fostering professional growth of the department.
Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA etc.) and demonstrates compliance with Home Health Foundation policies and procedures.
Grows referrals from assigned accounts and looks for opportunities to develop new accounts in the assigned territory through seeking out and maintaining relationships with physicians, key leadership, and management staff.
Exhibits leadership qualities by presenting as a positive role model and stimulating cooperation within the department and facilities.