Job Summary

The Clinical Liaison (CL) is responsible for education and outreach to support hospice functioning within the hospital and Skilled Nursing Facility setting for the referral process including coordination and communication with patients, families, and physicians. The CL will follow HSCC policies and procedures related to the GIP level of care and maintain systems to ensure hospice is compliant with all regulations. The CL will provide coordination for Hospice, Palliative Care and Transitions services as appropriate. The CL will represent the agency in the hospital and facilities while demonstrating sensitivity and compassion for patients and families facing life limiting illness, death and bereavement. This position requires an active RN license. Primary focus is in Santa Cruz County.

Essential Responsibilities

Facilitates admissions by consulting with patients and families to initiate the process in the hospital prior to transfer home or to a facility.

• Works with the hospital and physicians to identify patients who would benefit from Hospice, Palliative Care or Transitions support.
• Obtains and reviews medical records and other supporting documentation to determine hospice eligibility
• Meets with patients and families to explain hospice services and payment.
• Offers Information and Registration visits for hospice, Palliative Care or Transitions as needed.
• Facilitates transition to home or facility setting in conjunction with hospital discharge planners as indicated.
• Documents all referrals and admissions in the hospice clinical record
• Demonstrates accountability towards monthly / yearly admission, conversion rate
• Serves as an admission nurse or visit support as needed and available

Provides education for hospital professionals about hospice eligibility and HSCC services as well as regulations and symptom management.

• Collaborates and prepares current presentations as needed to hospital staff and referring physicians.
• Provides individual consultation regarding palliative/hospice care as needed.
• Communicates with case managers regularly to obtain and share information regarding hospice referrals.

Identifies, profiles, and networks with assigned skilled nursing facilities (SNFs), to maintain existing relationships and build new relationships, tracks and trends referral patterns.

• Identifies and creates account plans profiling key referral partners.
• Maintains existing relationships and builds new relationships as new SNF referral partners are identified.

Utilizes a scheduled call rotation and territory deployment processes to actively engage partners and assist them in identifying hospice eligible patients, resulting in increased hospice referrals.

• Determine frequency of calls to key referral partners (i.e. physicians, hospitalists, and assigned facilities) and reports progress bi-weekly.
• Consults with referral partners to educate them in determining hospice eligibility.
• Works with manager to set and reach specific goals for referrals from key facilities.
• Designs and employs ethical and effective strategies for meeting referral goals.

Works collaboratively with IDG Team Leaders to ensure facility relationships and protocols are followed by HSCC team and reports feedback to clinical leadership ensure optimal care of patients and excellent service to referral sources.

• Presents HSCC's Services and establishes the appropriate reporting scheduled to partners to ensure HSCC remains the hospice provider of choice
• Provides support and follow through with problem solving between facility and HSCC.
• Conducts routine systems review. Participates in the maintenance of systems and protocols between facility and HSCC.

Facility Education In-services and Protocols

• Arranges or provides educational in-services to facilities about hospice philosophy of care, hospice eligibility, and HSCC services
• Collects and reports data on service preferences of key facility staff.
• Maintains a database of key referral partners in each facility, including their communications and referral process preferences.
• Submits regular reports as needed to supervisor in a timely manner.
• Performs other related job duties as assigned by Supervisor

Maintains personal professional growth, focusing on communication skills, hospice clinical knowledge, and hospice eligibility criteria.

• Attend HSCC internal in-services as directed.
• Maintain current knowledge of the Medicare Hospice Benefit, billing issues, regulations and compliance, palliative care and end of life care.

The Hospital and SNF Liaison participates in other agency activities as assigned or as indicated.

• Attend monthly team meetings, general staff meetings, and committee meetings
• Participate in agency sponsored events or special projects.
• Other duties as assigned by supervisor.

Compliance

• Ensures compliance with all job related State/Federal Laws; ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, and all other regulatory/compliance requirements are understood and followed.
• Maintains up to date knowledge on SNF and RCFE regulations.

Requirements

Education/Experience

• RN required from an accredited University
• Hospice experience preferred but not required
• Experience in customer service preferred
• Bilingual strongly preferred

Skills Required

• Excellent verbal and written communication skills
• Excellent presentation skills
• Ability to develop and sustain effective working relationships
• Strong computer skills in Microsoft Office and competence using electronic medical records systems
• Critical thinking and ability to function both independently and as a member of a team

Certifications, Licenses, Registrations

• Current California Driver's License
• Pass OIG/GSA review and all required background checks
• Current CA RN License

Physical Demands

• Strength to lift and carry materials weighing up to 10 pounds
• Vision to read printed materials and a computer screen
• Hearing and speech to communicate in person and over the telephone

Work Environment/Environmental Condition

• Must possess mobility to work in a standard office setting and to use standard office equipment, including a computer
• Office work performed in combination of care facilities, hospitals and office environment.