Nurse Liaison

Let's tomorrow, together.

At Ubiquity, we live by the mantra head, heart, and hustle. Head because we use our collective industry know-how to always push ourselves, our clients, and our programs to be the best they can be. Heart because we are always gracious with our time, our collaboration, and with one another. And Hustle because we have grit, tenacity, perseverance, and a proven track record of meeting and exceeding goals—every person, in every role, for our company and our clients.

Sound like the right fit? Your tomorrow looks bright at Ubiquity.

Your Role:

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

As a 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 acute and/or post-acute care facilities. You will conduct in person, on site, face to face outreach, with facility Case Management/ Discharge Teams, and patients to discuss discharge planning and introduce the Post-Acute program. You will gather patient medical necessity needs and collaborate with hospital clinicians, patients and their family to develop a discharge plan of care and will coordinate post-acute care services for the patient and collaborate with Post-Acute homecare agencies on post-acute care plan of care, authorizing services as medically necessary.
 

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, patient goals and patient education/coaching along with adherence/compliance monitoring.
 

RESPONSIBILITIES

In this Job, you will:

• Determine the optimal site of care for patients post hospital discharge in collaboration with hospital discharge planners, case managers, hospitalists and Medical Directors.

• Manage and influence the transition of assigned Post-Acute Care patients from acute care setting to the SNF, IRF, LTACH or home setting utilizing face to face and/or telephonic outreach.

• Help coordinate the orders for home health and other post-acute care services.

• Contact referral sources to advise and relay updates to the appropriate individuals.

• Partner closely with the PAC 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.

• Document all interactions, problems, goals and interventions to meet documentation guidelines.

• Work closely with the home health agencies and post-acute providers to ensure a smooth transition to home or facility with appropriate services.

• Act as a clinical resource for unlicensed staff, to provide clinical expertise and help with referral source directives, clinical questions and issues.

• Communicate facility or market level trends related to census, diagnosis, barriers to discharge and social determinants of health factors for your market population.

• Participate and contribute to ongoing quality assessment/improvement activities, performance, data collection, analysis, operational process activities and prepares reports.

• Assist team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.

• Participate in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.

• Participate in special projects and perform other duties as assigned.

This is the job for you if:

• You are willing to travel daily to local hospitals, SNF, IRF, LTACH and physician offices 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.