Clinical Transition Liason

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, the role involves assessing, planning, implementing, and evaluating the care needs of designated patients or providing nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed. It is a professional individual‑contributor role that may direct the work of other lower‑level professionals or manage processes and programs.

The majority of the time is spent overseeing the design, implementation or delivery of processes, programs, and policies using specialized knowledge and skills typically acquired through advanced education. This senior level role requires advanced knowledge of the job area typically obtained through advanced education and work experience. The person is typically responsible for managing projects and processes, working independently with limited supervision, coaching and reviewing the work of lower‑level professionals, and resolving difficult and sometimes complex problems.

The role is responsible for generating home health and hospice referrals in a designated territory or facility while serving as a 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, demonstrate a clear understanding of how referral sources make decisions and identify decision‑makers.

The liaison collaborates 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.

• Massachusetts RN Licensure and NH Licensure.
• Valid state issued Driver’s License.
• Two (2) years of home health experience.
• Basic Life Support Certification.

• Case management experience.

• Increase census through marketing of geographically defined areas and develop specific referrer relationships with potential referrers.
• Develop specific referrer relationships with hospitals/community in defined geographic areas with primary focus on case management departments or as determined by the marketing team.
• Provide 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.
• Schedule educational programs at hospitals in geographically defined areas to be given by Liaison, Program Coordinators, or other HHF staff as appropriate.
• Notify referring agencies/personnel of patient’s progress at HHF as appropriate. Deliver/mail all discharge summaries to social workers and discharge planners in defined territory.
• Achieve business development targets such as conversation ratio of referral to SOC, hospital admission targets, and contacts/evaluations through detailed marketing plans. Supply data for statistical reports and assess implications of data collection and participate in strategic planning.
• Seek out opportunities to become a preferred provider or partner for the account rather than solely a vendor.
• Maintain an ongoing, intimate knowledge of all HHF product lines and services and promote them as appropriate with the account.
• Seek out opportunities to participate or attend account meetings, task forces, clinical teams, etc. where HHF expertise in post‑acute care would benefit the account (e.g., ACO committees, re‑admission groups, leakage management efforts). Identify circumstances where it would be appropriate/expected to involve participants representing HHF’s clinical departments in order to add particular expertise or leadership.
• Understand the competitive landscape in general and the individual competitors for each assigned account.
• Complete pre‑admission screening process and facilitate home assessment as per policy and present to intake office to facilitate timely and appropriate SOC.
• Utilize assessment skills to…