THE OPPORTUNITY:

In this role, the Digital Transitional Service Liaison is an on-site hospital-based position responsible for leading a high quality and cost-efficient Transitional Care Program. The position is focused on patient identification, optimal discharge disposition planning, patient education, and coordination across the continuum of care. The Transitional Services Liaison focuses on identifying barriers to discharge to meet hospital metrics such as length of stay, readmission prevention, and appropriately referring patients into the proper external care management programs. Aiming to get patients to the appropriate level of care in the post-acute care space.

The Transitional Services Liaison provides support to the clinical team including case management by adhering to standardized workflows that support appropriate next level of care planning and sharing program data with appropriate hospital staff. This role works closely with the patient's clinical team, case management, and post discharge planning resources available at the time of discharge. This position will involve both in-house and telephonic management of patients.

JOB FUNCTIONS

• Implements Transitional Care Program within Hospitals, focused on high quality, cost-effective transitional care.
• Performs patient centered standardized assessments.
• Participates in multidisciplinary rounds, Coordinates care across the continuum in collaboration with internal case management and discharge planning teams.
• Patient (and caregiver/family) education and assigned of Ceras Health Transitional Care wearable health monitoring devices.
• Discharge disposition planning and implementation.
• Develops strong working relationships with key hospital personnel and post-acute care partners.
• Uses data and clinical expertise to drive program performance communicating with key internal and external stakeholders to assist in continually improving clinical care and performance using best practices.
• Meets regularly with internal / external staff to review data and develop strategies that drive continuous improvement.
• Works with management and is responsible for monthly performance targets based on real time metrics as well as claims-based data.
• Understands and can articulate the value of the Ceras Health Transitional Care Program and other service offerings to patients and families.
• Educates hospital team on specialty programs and collaborates on performance improvement opportunities.
• Assists key stakeholders in implementing care via partnered and preferred agencies.
• Tracks feedback received from patients, families and others regarding programs and preferred facilities for process improvement opportunities.
• Completes documentation in approved platforms and EMR’s per program expectations.
• Responsible for the implementation of Care Improvement initiatives and principles related to achieving quality and patient satisfaction outcomes.
• Demonstrates leadership that creates and fosters a culture of continuous improvement.
• Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures.

EDUCATION, QUALIFICATIONS, & EXPERIENCE

• Holds a current license in good standing as a LPN or RN. Will consider a seasoned CMA with business development skills.
• Graduate of an accredited and approved nursing program as indicated by school transcript or diploma.
• 10 years’ hospital experience, with at least 5 years’ experience in hospital care management.
• Demonstrated record of strong interpersonal skills.
• Demonstrated knowledge of Medicare and other program requirements, as applicable.
• Previous discharge planning experience preferred.
• Proficiency in collaborative tools such as Word, Excel, Powerpoint and Access.
• Experience in handling multiple projects and deliverables within deadlines.
• Commitment to continuous learning and improvement.
• Must be proficient with technology. Various digital devices are utilized in this program.

ABOUT YOU

You will thrive at Ceras Health if you have:

• The desire to work collaboratively with a tight knit but quickly growing team across many different areas of the business.
• Flexibility, humility, and a sense of humor
• Drive and excitement for working in a fast-paced environment.
• Has a love for new technology as it is developed.

Ceras Health offers a comprehensive compensation and benefits package, including paid time off, medical, dental, and vision insurance, company paid life insurance and retirement savings.

COMPANY BACKGROUND

Ceras Health is a digital first, integrated care provider combining clinical expertise, digital health devices, artificial intelligence, and behavioral change solutions to empower individuals to take control of their health and learn ways to extend and improve the quality of their lives. Ceras Health has developed a SaaS and mobile platform, that supports patients’ adherence to pre- and post-discharge care plans, provides patients and care team members with the ability to measure and track patient health data, and enables individuals to get better and stay better providing access to condition specific health information.

For more information about Ceras Health, please visit www.cerashealth.com, and follow the company on Twitter, Facebook, and LinkedIn.

Ceras Health’s policy is to provide equal employment opportunity and affirmative action in all its employment practices without regard to race, color, religion, sex, national origin, ancestry, marital status, protected veteran status, age, individuals with disabilities, sexual orientation or gender identity or expression or any other legally protected category. Verification of employment eligibility will be required as a condition of hire.