Job Description

This is a full-time professional nursing position that is responsible for coordinating referrals for all Transitions LifeCare (TL) service lines and is an essential point of contact for developing and maintaining strong relationships with hospital staff and leadership. The Nurse Liaison serves as the first line point of contact for referral processing, admission coordination, and discharge planning in the hospital setting. In addition to referral coordination, the Nurse Liaison assists active TL patients with transitions of care in the hospital setting and acts as the hospice nurse case manager for active hospice patients admitted to the hospital under general inpatient level of care – this includes coordinating the hospice plan of care with hospital staff and hospice IDG members. The RN Liaison provides education and support to patients, families, hospital staff, and referral sources regarding end-of-life care and all TL services, by assisting with goals of care conversations and providing informational visits within the hospital setting as well as in other community-based locations as needed. Finally, this position partners closely with TL Provider Relations to implement results-oriented, innovative education, customer service, account management, and marketing strategies, within assigned hospitals, with the goal of providing exceptional support to referral sources and promoting excellence in end-of-life care. These duties will be performed in a manner that is consistent with Transitions LifeCare’s mission statement, core values, and regulatory requirements. The schedule for this position is Saturday/Sunday/Monday 7a - 7p; one major and one minor or three minor holidays per year.

Responsibilities (what you do)

• Provide informational visits, education, and support to patients and families referred for TL services in hospitals and other community-based settings, upon request.
• Utilize expert-level assessment skills and critical thinking to implement on-site referral coordination for all TL service lines.
• Coordinate with appropriate hospital staff to promote a seamless transition from hospital discharge back to the community setting, or hospice inpatient setting, with TL support.
• Assist hospital staff and referral sources in identifying appropriate service lines and hospice level of care to provide optimal patient and family support.
• Appropriately assess patients’ eligibility for direct admission to the TL Hospice Home, as requested, utilizing Medicare guidelines for Hospice General Inpatient Level of Care and TL admission criteria.
• Plan, provide, and document safe, competent, and compassionate nursing care to patients and families in the hospital setting in accordance with provider orders, TL established policies and procedures, and related regulatory guidelines.
• Complete hospice general inpatient level of care admissions in assigned hospitals and act as hospice nurse case manager for patients under GIP level of care in the hospital setting.
• Coordinate care for hospitalized hospice, palliative care, and home health patients with appropriate hospital staff and TL IDG members.
• Provide emotional support to patients, families, and hospital staff coping with the challenges that accompany end of life decision making and care.
• Provide approved, patient and family-centered educational resources to patients, families, and referral sources regarding all TL service lines, common end of life interventions/care, and bereavement support, as appropriate.
• Provide in-service training to hospital staff regarding all TL service lines and end of life care, as assigned.
• Work collaboratively with TL Provider Relations to provide education and promote TL services within targeted facilities with the goal of increasing referrals, length of stay, and daily census.
• Assist in fielding, documenting, and addressing patient, family, or referral source feedback. Work to resolve any concerns in a timely manner and communicate resolution to appropriate parties.
• Continue personal, professional development by maintaining required competencies, participating in continuing education, and identifying learning opportunities by seeking appropriate assistance or education offerings.
• Participate in the identification of clinical or operational performance improvement opportunities and participate in organizational performance improvement initiatives.
• Actively participate in the orientation and training of new employees of all disciplines.
• Perform other duties, as assigned, by the Nurse Liaison Team Leader.

Expectations how you do it

• Model professionalism and empathy by consistently demonstrating compassion, respect, teamwork, and dedication in all interactions with coworkers, customers, and partners.
• Adhere to all TL policies, procedures, and organizational guidelines, ensuring compliance in daily work and decision‑making.
• Deliver care and services in accordance with ACHC Standards and Medicare Conditions of Participation when applicable to your role.
• Comply with all relevant state and federal laws, regulations, and professional standards within your defined scope of responsibility.
• Promptly communicate concerns, issues, or potential risks to your immediate supervisor or another member of the management team to support a safe and effective work environment

Requirements (what you need)

• Requires expert level analysis of patient clinical information and formulation of an accurate assessment of the patient and his/her condition.

• Ability to independently seek out resources and work collaboratively to achieve goals/objectives.

• Strong critical thinking, communication and organizational skills required to be effective in this role.
• Proven ability to prioritize workflow and multitask with excellent time management skills.
• Solid work history demonstrating robust interpersonal skills.
• Strong computer skills required; experience with Netsmart, Outlook, and Office 365 preferred.
• Registered Nurse with current NC license; BSN preferred.
• Minimum 2 years recent clinical experience. Hospice and/or home health or nursing home experience or equivalent preferred.
• Workdays and scheduled hours with weekend and holiday commitments as outlined in Employee Information Agreement.
• Broad knowledge of hospice, home health, palliative care, and private duty services, reimbursement considerations, and related regulations/standards.
• Current CPR certification.
• Must have and maintain a valid North Carolina Driver’s License, maintain automobile insurance coverage and have access to reliable transportation.
• Must be able to travel to, enter and function in the homes/facility of any patient/family in the service area to assess and provide care to all patients.
• May be required to lift and/or carry items up to 50 pounds.
• Must have sensory abilities to complete physical assessment, communicate with patient/family care providers and physician and to complete the reporting and follow-up documentation responsibilities of the job.