Transition Liaison (RN/SW)
Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.
The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.
Position Purpose: The Transition Liaison is a hospital-based position responsible for ensuring that Steward's ACO risk patients is highly coordinated with high quality and cost-efficient outcomes. The position is focused on patient identification, optimal discharge disposition planning, patient education and coordination across the continuum of care. The Transition Liaison focuses on 1.) identifying barriers to discharge to meet hospital metrics such as length of stay, and readmission prevention, 2.) appropriately referring patients into Steward’s internal care management programs, and 3.) aiming to get patients to the appropriate level of care in the post-acute care space. The Transition Liaison provides support to the clinical team including case management by adhering to standardized work flows 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, physical therapy, and post discharge planning resources available at the time of discharge. This position will involve both in-house and telephonic management of patients.
- Implements ACO Risk/ BPCIA Program strategy within Steward Hospitals, focused on high quality, cost- efficient care, including but not limited to:
- Patient identification
- Performs patient centered standardized assessments including SDOH barriers and readmission risk
- Participates in multidisciplinary rounds
- Coordinates care across the continuum – example daily huddles with PAC partners
- Patient (and caregiver/family) education
- Discharge disposition planning and implementation
- Refers member beneficiaries to appropriate SHCN Care Management Programs, provides warm handoff
- 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 is able to articulate the value of the Steward Network to patients and families while maintaining a patient's right to choose
- Educates hospital team on specialty BPCIA 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 Care Radius per departmental expectations
- Works collaboratively with hospital department leaders
- Is integral in working with SHCN's IT department to ensure the maintenance of care management databases and use of care management documentation systems. Proactive about identifying and advocating for system enhancements that may be required to deliver high quality care management services. Collaborates with IT teams to implement, test, and deploy system upgrades and enhancements
- Responsible for the implementation of Care Improvement (LEAN) 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
- Other duties as assigned
Education / Experience / Other Requirements
- Certified RN, Physical Therapist, Social Worker
- Minimum 4-year degree
- Broad clinical background desired
Years of Experience:
- Minimum three-five years' experience in care management role (preferably in a hospital setting)
- Physical therapy/social work experience should include in a hospital setting
- Excellent critical-thinking, observation, written /verbal skills, problem-solving, and analytical skills
- Ability to lead and motivate others to execute a plan in a rapidly changing environment
- Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes. Highly organized and ability to work autonomously
- Knowledge of governmental rules and regulations and hospital standards
- Strong current working knowledge of Accountable Care Organization (ACO) desirable
- Knowledge of leading practice in clinical care and payer requirements
- Familiarity with the compliance and regulatory standards governing health plans and patient care including NCQA, URAC, federal, state, and other regulatory requirements
- Ability to use Microsoft Office tools including Word PowerPoint, Excel, and Outlook
- EHR proficient
- Current clinical license
- Valid driver's license and an insured vehicle in proper working order for local travel
This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.
Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.
Steward Health Care Network is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.
Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience:
- Any COVID-19 related care takes place in designated areas away from other patients and their families.
- A stringent cleaning policy has been implemented throughout our facilities.
- A strictly controlled visitor and masking policy is required for patient and colleague safety.
You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.