Care Transition Liaison, Rn

We're saving lives, building careers, and reimagining healthcare. We can't wait to grow alongside you.

The great history of Home Health Foundation is now the future of Tufts Medicine Care at Home.

Tufts Medicine Care at Home is a proud member of Tufts Medicine, a health system that is rethinking how academic and community centers, local and national businesses, and technology and service innovators can all work together. So that clinicians can deliver expert care where it's needed most and so that we can bring wellness back to health care, one person at a time.

Why Join Us?

Benefits you'll love - Up to $12,500 Sign on Bonus, Generous earned time package, Retirement plan with employer match, Tuition reimbursement and more!

Job Overview

As a key member of the health care team, the Home Care Liaison must interact courteously and effectively with patients and their families, as well as with co-workers from all Agency departments, community resources, and with patients' physicians. The Home Care Liaison carries out their responsibilities consistent with Agency policies, mission, and vision.

Location: In-Patient Lowell General Hospital - Lowell, MA

Hours: 40 hours Monday thru Friday 8:00am to 4:30pm

Minimum Qualifications

• Active RN licensure in Massachusetts and New Hampshire Minimum

• 2 years of relevant clinical experience.

• Home care and /or population health desired.

• Ability to read/write and communicate in English.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

Essential Functions

• Coordinate home care for high-risk patients in the in-patient setting, collaborating with case managers, patient population nurses and TMCAH

• Compassionate conversations with patients/families regarding services offered in the home environment

• Conducts a full needs assessment. Responds to all referrals and inquiries promptly

• Notifies the appropriate clinical team of impending admission and any pertinent information. Upon discharge, continues follow-up for a total of 14 days

• Follow up of phone calls to patients that are scripted and focus on in-hospitalization assessment to identify any clinical changes to prevent a re-hospitalization

• Post hospitalization documentation with nightly report sent to multiple clinical departments

• Informs physicians, hospital personnel, patients, families, and other interested groups about available services

• Collaborates with physicians, case managers and managed care case managers

• Determines appropriateness for home health services or hospice care

• Provides information about specific agency programs and services

• Assists physicians, hospital personnel, patients, and families in pre-discharge planning

• Discusses home health services or hospice options with the physicians, nurses, patients, and families. Assists with the coordination and establishment of a transitional care plan for home health services and hospice

• Facilitates the provision of appropriate services; Infusion Therapy, tele health

• Demonstrates a knowledge and understanding of what to report to the CEO or Chief Compliance Officer when concerns of corporate compliance arise. Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA etc.) and demonstrates compliance with Tufts Medicine Care at Home policies and procedures

• Practices confidentiality principles set by the agency and federal HIPAA/HITECH guidelines. Participates in all mandatory in-services

What We Offer:

• Competitive salaries & benefits that start on day one!

• 403(b) retirement with company match

• Tuition reimbursement

• Career opportunity growth

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org.