RN Home Care Liaison
About The Position
The RN Home Care Liaison collaborates with hospital and/or clinic caregivers as a resource regarding home care services, providing general education. They educate patients and families on home care, palliative care, and hospice services, answering questions to help patients make informed decisions about their discharge plan for post-acute care. The role involves attending outcome facilitation team meetings to provide input on home-based services, communicating with social workers or case managers on complex cases, and building relationships with physicians, nurses, social workers, case managers, and community partners through effective communication regarding patient transitions. The liaison visits patients prior to discharge to ensure they meet CMS regulations and understand provider orders for home care, palliative care, or hospice services if Aurora At Home is chosen. They collect and record relevant medical, social, and reimbursement data from hospital/clinic records to initiate services and follow up on readmitted patients to evaluate their need for further services. Additionally, they collaborate with caregivers and patients/families regarding financial coverage of all Aurora At Home service lines and provide information prior to discharge if available. The position requires the ability to provide age-appropriate care, demonstrating knowledge of growth and development principles and assessing patient needs based on age-specific requirements.
Requirements
- Registered Nurse license issued by the state in which the team member practices.
- Associate's Degree in Nursing.
- Typically requires 3 years of experience in clinical nursing including experience with discharge planning and/or case management.
- Excellent communication skills. Must be able to speak clearly and hear to communicate with people in person or over the telephone.
- Good organizational, analytical and problem solving skills.
- Proficiency in clinical skills with the ability to work under direction and make sound judgments.
- Demonstrated ability to educate clinical staff and the community.
- Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
- Ability to work in a team based environment and participate on multiple teams.
- Must have a thorough understanding of home care reimbursement to include Medicare, Medicaid and private insurance or ability to learn criteria.
- Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs.
- Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families.
Responsibilities
- Collaborates with both hospital and/or clinic caregivers as a resource regarding home care services and provides general education of services.
- Educates patients/families on home care, palliative care, and hospice services and is available to answer questions allowing patients to make an informed decision regarding their discharge plan for post-acute care.
- Regularly attends the outcome facilitation team meetings on the individual hospital units to provide input regarding services that could be provided in the home.
- Communicates with social workers or case managers on complex cases.
- Builds relationships of mutual respect with hospital and clinic based physicians, nurses, social workers, case managers, and community partners by providing good communication regarding patient transitions.
- Visits patients prior to discharge to ensure patients meet criteria for Centers for Medicare & Medicaid Services (CMS) regulations and has an understanding of provider orders for home care, palliative care, or hospice services upon patient selection of Aurora At Home as the provider of choice.
- Collects and records medical, social, and reimbursement data from the hospital and/or clinic record pertinent to initiating Aurora At Home home care, palliative, hospice, DME, RT, enteral, and infusion services.
- Follows Aurora At Home home care, palliative, and hospice patients readmitted to the hospital and evaluates their need for further services.
- Collaborates with hospital and/or clinic caregivers and patient/family regarding financial coverage of all Aurora At Home service lines, and if available, provides information prior to hospital discharge.
- Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.
- Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.
Benefits
- Comprehensive suite of Total Rewards: benefits and well-being programs
- Competitive compensation
- Generous retirement offerings
- Programs that invest in your career development
- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Flexible Spending Accounts for eligible health care and dependent care expenses
- Family benefits such as adoption assistance and paid parental leave
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
