Job Summary

The WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care – from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care. WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.

General Summary

The Clinical Liaison is responsible for managing the ongoing hospital census of WellBe's patients. This candidate will help educate patients about WellBe’s program, close gaps in communication between patients and attending physician, and coordinate smooth transitions post-discharge. This candidate will also be responsible for care coordination needs and supporting WellBe clinicians and Community Medical Director (CMD) with operational and clinical tasks.

Job Description

SKILLS & COMPETENCIES

• Fosters a culture of best demonstrated practices, customer and peer service-orientation, measurement, performance, accountability, and continuous improvement
• Manage the Transition of Care Process from admission to transition home (i.e, admission, discharge planning and follow-up)
• Monitors active patients across care settings (hospitals and SNF’s)
• Visit facilities (hospital and SNF’s on a routine basis)
• Serves as a resource for the patient and their family to help solidify discharge and treatment plan
• Facilitation and clarification of patient’s goals of care with the facilities and attending physicians
• Assists with discharge planning from Inpatient or Skilled Nursing settings
• Works collaboratively with the clinical coordinator to ensure discharge data is appropriately documented and transition of care visits are scheduled and verified with the patient/family
• Collaborates with Community Medical Director daily to review the appropriateness of discharge plans
• Reviews with the CMD the medical necessity of Home Health orders, orders for DME, and follows up with those HH agencies and DME agencies on their treatment plan
• Facilitating access for the patients to verify their ancillary services such as DME, Home Health, OP Rehab are in place and meeting their needs
• Attends Interdisciplinary Team (IDT) meetings and provides additional information on patients
• Face of WellBe in the hospital/SNF if physicians cannot be onsite (e.g., bring in notes, POLST, etc.), patients know them as WellBe, and they are part of their WellBe program
• Assist physicians with communicating with attending of record
• Arranges family meetings in the SNF and hospital
• Develop relationships in admitting, ED and Case Management departments in facility setting
• Coordinates with Facility’s Case Management and Social Work Teams on the discharge
• Develops relationships with SNF Administrators
• Obtains access to clinical records in the facility setting, and reviews and facilitates medical records transfer to WellBe
• May conduct home visits based on community team needs
• Ability to explain the WellBe model and engage new members into the program
• Other tasks needed to accomplish team’s objectives/goals

Job Requirements

QUALIFICATIONS

Educational/ Experience Requirements:

• Minimum of 5 years as a Licensed Practical Nurse/Licensed Vocational Nurse Health Plan/ Hospice Liaison experience preferred.
• LPN/LVN Licensure required.
• Managed Care experience preferred.

Required Skills and Abilities:

• Superior interpersonal skills
• Experience charting in EMR skills
• Detail orientation
• Problem solving and thinking autonomously and owning the solution
• Professional demeanor
• Knowledge of Geriatric Medical Practice/Terminology
• Innovative
• History of successful outcomes or quality-driven practices
• Ethical patient care
• Teamwork/Can-Do Attitude
• Advanced computer skills (ie. Excel filtering and advanced features, Google/Gmail, etc.)
• Strong communication skills (verbal and written)

Travel requirements: Travel may be required up to 100% locally.

Work Conditions: Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs. Ability to stand for extended periods.

Ability to drive to patient locations (ie. home, hospital, SNF, etc). Fine motor skills/Visual acuity

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position. Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role