Home Care Community Liaison

Summary:

In cooperation with the patient's primary care physician, hospitalist and hospital/ECF staff, this position facilitates the home care referral and admission process from the hospital/ECF to ensure a smooth transition to home for the patients. Responsible for attending hospital rounds, facilitating orders, assessing patient needs, DME, medications and transportation. Enters referral information into the Electronic Medical Record, completes the referral process and forwards hospital documents to the Home Care Office. Provides education to hospital staff and physicians. This position is the Agency's first contact with referral sources, patients, and their families. Reports to the Home Care Clinical Supervisor.

Responsibilities:

1. Records referral data for patient care, from multiply sources, into the appropriate log books and computerized programs.
2. Develops a thorough knowledge base necessary to appropriately accept or refuse cases referred for care, to include an in-depth knowledge of Medicare, private insurance, HMO and Title 19 and all payors contracted with agency. Any case refused for care will be reviewed with a supervisor.
3. Notifies the appropriate program supervisor of new referrals. (Home Health Nursing, HHA, Therapy, Maternal Child Health, Social Work).
4. Reviews all potential referrals for appropriateness of home care, to include review of the facility patient record, discussion with the facility staff and patient physician, and consulting with the patient and/or family caregiver prior to patient discharge to home to ensure a smooth transition from facility to home. This includes attending hospital rounds.
5. Initiates the medication reconciliation process, supply/equipment ordering, assesses level of and initiates patient education and other key components as part of the transition from facility to home.
6. Confirm scope and specifics on insurance coverage necessary to obtain payment on case by phone and clearly documents all necessary information on intake form. Collects and provides clinical data from patient charts for insurance company queries. Provides managed care forms and/or patient education tools in admission chart, as necessary.
7. Assists with supervision of assigned nursing, therapy and HHA personnel in delivery of nursing services on weekends and holidays.
8. Participates in other nursing duties as assigned by the Clinical Supervisors or Executive Director.
9. Fulfills all compliance responsibilities related to the position.
10. Performs other duties as assigned.

Education: ASSOCIATE'S LVL DGRE

Other Information:

Required: RN License in New York. Make independent nursing judgements. Computer data input/keyboard operations. Knowledge of managed care operations, Medicare and Medicaid and other payer sources. Deals with a high degree of public contact and interactions.
Minimum Experience: one year
Desired: Knowledge of McKesson Electronic Home Care Medical Record. Knowledge of Soarian Clinicals Electronic Medical Record, Knowledge and use of software packages for office management and electronic medical record. Bachelor's Degree in Nursing.

Working Conditions:

Manual: Some manual skills/motor coord & finger dexterity

Occupational: Some occupational risk

Physical Effort:

Physical Environment: Some exposure to dirt, odors, noise, human waste, etc.

Credentials:RN