RN, Home Care Liaison

University of Rochester•City of Rochester, NY

2d•$37 - $48•Onsite

About The Position

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. This role involves reviewing the medical record and collaborating with the interdisciplinary team and the Care Coordinator to facilitate discharge management. The patient discharge requirements will be met within the scope of Home Care Referrals and Patient Review Instruments (PRI) for nursing home placement. The RN, Home Care Liaison identifies patient discharge needs and is accountable for patient discharge, assisting in implementing patient care strategies to close gaps in medical care upon discharge. They identify resources for patient self-management planning and discharge, and participate in the development of discharge plans with short- and long-range care plan goals for patients. This position coordinates care of patients, assuming a coordination role at the point of admission and through discharge, with targeted coordination and follow-up. They assist in developing and implementing care plans for medically complex patients and identify barriers to a successful discharge plan. Effective interaction with physicians, acute care team, patients, and caregivers is essential. The role coordinates the use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan and facilities discharge. The position requires staying abreast of organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature, and maintaining professional contacts in the community. Assistance with the development of current evidence-based protocols, policies, work flow/flow sheets, guidelines, etc. related to the provision of care within the acute care model is also a responsibility. Participation in committees as assigned and providing coverage for all units as needed for absences and vacancies are also part of the role. Other duties as assigned.

Requirements

Associate's degree in Nursing and 5 years of professional nursing experience required
RN - Registered Nurse - State Licensure and/or Compact State Licensure in New York State (NYS) upon hire required
Proficient computer skills required
Familiarity with electronic medical record required

Nice To Haves

Bachelor's degree in Nursing preferred
Equivalent combination of education and experience
Experience in acute care, community health care management, disease management and working with multidisciplinary teams preferred

Responsibilities

Reviews the medical record and collaborates with the interdisciplinary team and the Care Coordinator to facilitate discharge management.
The patient discharge requirements will be met within the scope of Home Care Referrals and Patient Review Instruments (PRI) for nursing home placement.
Identifies patient discharge needs and is accountable for patient discharge.
Assists in implementing patient care strategies to close gaps in medical care upon discharge.
Identifies resources for patient self management planning and discharge.
Participates in development of discharge plan with short- and long-range care plan goals for patients.
Coordinates care of patients.
Assumes coordination role at the point of admission and through discharge, with targeted coordination and follow-up.
Assists in developing and implementing care plans for medically complex patients.
Identifies barriers to a successful discharge plan.
Interacts effectively with physicians, acute care team, patients, and caregivers.
Coordinates use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan and facilities discharge.
Keeps abreast with organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature, and maintaining professional contacts in the community.
Assists with the development of current evidence-based protocols, policies, work flow/flow sheets, guidelines, etc. related to the provision of care within the acute care model.
Participates in committees as assigned.
Provides coverage for all units as needed for absences and vacancies.
Other duties as assigned.