RN, Home Care Liaison

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.
• Affords assistance in implementing patient care strategies to close gaps in medical care upon discharge.
• Identifies resources for patient self-management planning and discharge.
• Collaborates in the development of discharge plan with short- and long-range care plan goals for patients.
• Captures coordination role at the point of admission and through discharge, with targeted coordination and follow-up.
• Affords assistance 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.
• Collaborates in the coordination of 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.
• Affords assistance in 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.

Requirements

• Associate's degree in Nursing and 5 years of professional nursing experience required
• 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

Qualifications

• Proficient computer skills required
• Familiarity with electronic medical record required

Skills

• Proficient computer skills
• Familiarity with electronic medical record

Benefits

Commensurate with experience.

Pay

$36.73 - $47.75

Schedule

As Scheduled