Nurse Liaison - Post Acute Care (Middlesex, NJ)

Overview

Do you live in the Middlesex, New Jersey area?

Are you able to travel to hospitals, healthcare facilities, and/or to patients’ home in the Middlesex, New Jersey area for this job?

 

Are you an experienced Registered Nurse with a passion for shaping the future of healthcare?

As a Post-Acute Care Nurse Liaison you will be an expert in resource management, a master of utilization review and a compassionate partner for patients and their support network. You will be responsible for an assigned caseload at post-acute care facilities. You will conduct in person, on site, face to face outreach with patients to introduce the post-acute care program. You will gather patient demographics and collaborate with post-acute care clinicians and patients and their family to develop a discharge plan of care, coordinate post-acute care services and collaborate with post-acute homecare agencies on post-acute care plan of care, authorizing services as medically necessary.CareCentrix is dedicated to connecting care to create a seamless health journey for patients across care settings. The Post-Acute Care program helps to reduce hospital readmissions of patients and has aspects of education and coaching to assist patient’s transition home after a hospital stay. The program works directly with patient treatment plans, facilitates in home health care services to accomplish the treatment plan and patient goals and education/coaching along with adherence/compliance monitoring.Post Acute Care Nurse Liaisons are Registered Nurses who work with patients in post-acute facilities and residential settings. They perform as part of a care team including a Nurse Practitioner, Medical Director and other supporting team members. They deliver role appropriate coaching through in-person visits, telephonic outreach and interdisciplinary team activities.

Responsibilities

In this Job, you will:

• Determine the optimal level of care for patients in collaboration with facility discharge planners, case managers, clinicians and CareCentrix Medical Directors
• Work collaboratively with the multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care
• Assess patient needs for community resources and appropriate referrals for service
• Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery
• Manage and influence the transition of assigned Post-Acute Care patients from SNF or IRF to the home setting utilizing face to face and/or telephonic outreach.
• Help coordinate orders for home health and other post-acute care services.
• Partner closely with the CareCentrix Medical Director in reviewing discharge plans and length of stay status to ensure optimal outcomes.
• Communicate customer service/provider issues to supervisor for logging and resolution.
• Engage and coach patients/caregivers on progress toward goals, safe transitions to the next site of care and readmission avoidance resources.
• Educate, coach and influence patient and caregiver behavior to achieve care plan goals.
• Document all interactions, problems, goals and interventions to meet documentation guidelines.
• Facilitate the patient’s transition within and between health care settings in collaboration with the treating physicians
• Work closely with home health agencies and post-acute providers to ensure a smooth transition to home or facility with appropriate services.
• Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs

This is the job for you if:

• You are willing to travel daily to local health care and residential settings within assigned geography locations.
• You can work independently, utilizing sound clinical judgment and critical thinking skills under minimal supervision.
• You have a strong commitment to quality and standards.

Qualifications

You should get in touch if: (Education, skills and experience)

• You hold a current and unrestricted Registered Nurse license. (Required)
• You have a minimum of five years RN experience (Required- preferably with a geriatric population).
• You are an expert in Utilization Management and have knowledge of URAC & NCQA standards.
• You have a broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, prior utilization management/case management experience, and governmental home health agency regulations. (Required)
• You possess negotiation, communication, influencing, problem solving and decision-making skills. (Required.)
• You possess a high-level clinical knowledge, communica