RN Transition Liaison

Job Overview

The position is a member of the hospice staff who determines appropriateness of referrals, coordinates and conducts pre-admission activities, completes admission when determined hospice appropriate, monitors inpatient care at contracted hospitals, performs in-service training and community education activities. This position performs duties in a variety of settings including 6patient’s home, acute care setting, skilled nursing facility or assisted living.

Location: Melrose Wakefield Hospital, and occasionally Melrose Health Center and Bear Hill

Hours: Day Shift- 8-4:30

Job Description

Minimum Qualifications:

1.Massachusetts RN Licensure.

2.Hospice and/or end of life experience required.

Duties and Responsibilities: The duties and responsibilities listedbelow 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.

• Describes and explains hospice services to a potential patient and/or family member and elicits responses to questions regarding attitude towards hospice care, evaluates physical and psycho/social/emotional status, in order to put the patient and family at ease about choosing hospice and fully inform them about the program. 

• Works with hospice intake and eligibility department to verify insurance reimbursement for each referred patient and document in EMR.

• Reviews and explains to patient and/or family about insurance coverage and financial obligations, using knowledge of hospice fees, costs and reimbursement sources. Escalates to referral management director and/or referral manager, in circumstances of potential admission where reimbursement sources appear not to cover hospice fees, to ascertain whether reduce fee or free care may be offered. 

• Introduces and explains benefits of hospice care and familiarizes decision makers with characteristics and needs that indicatean appropriate hospice referral. Presents the advantage of the hospice Medicare/Medicaid benefits to referral sources.

• Thoroughly understands the Medicare/Medicaid hospice benefit, the Medicare home health benefit, the Medicare/Medicaid long term benefit and the Medicare HMO benefit.

• Documents a narrative note in the EMR summarizing pertinent physical and psychosocial information from the hospital record and/or from the physician and patient/family assessment. Reviews referred patient’s history, medical status, and prognosis to determine eligibility for hospice services relying on the knowledge of hospital procedure and hospice admission criteria.

• Completes the patient/family admission packet, including obtaining signed Notice of Election of Hospice Benefit (NOE), admission forms from the patient, family, referral source and the attending physician. Uploading completed admission documents electronically to medical records for them to complete their process.

• Communicates information from Comprehensive Assessment to TMCAH CMO, hospice physician or TMCAH covering NP. Documents results and performs warm hand off to team.

• Communicates NTUC to appropriate staff and managers. Documents reason and continuation of care measures implemented.

• Promotes hospice services, to ensure appropriate referrals to hospice program, may perform liaison activities centered in the acute care setting, which include but not limited to, case conferences to case managers, discharge planners, physicians, other health care providers and referral sources.

• Works with TMCAH liaison and intake staff to ensure ease of referral, as well as a rapid response to the referral source.

• Evaluates and compares information,regarding referred patient to hospice criteria. Consult with either the referral management director, referral manager, CMO, or hospice physician when an admission is questionable.

• Communicates on a regular basis with patient, family, referral source, hospice intake or liaison staff, to ensure continuity of care and adherence to the hospice plan of care.

• Develops opportunities for and conducts in-service presentations in health care facilities regarding hospice care and the indications for a hospice referral.

• Joins approved professional organizations and other groups which include key decision makers in the care of terminally ill patients.

• Assists with public relations activities to promote community awareness of Hospice services.  Includes activities during National Hospice Month.

• Reports Compliance concerns to the CEO or Chief Compliance Officer when applicable.

• Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA etc.) and demonstrates compliance with Tufts Medicine Care at Home policies and procedures.

• Gathers all pertinent information necessary for admission.

What We Offer: 

• Competitive salaries & benefits that start on day one!
• 403(b) retirement with company match
• Tuition reimbursement
• Generous PTO Package
• Mileage reimbursement
• Fleet Car Program