Reporting to the Associate Director of Transition of Care, the Transitions of Care Clinical Liaison would be responsible for evaluating and facilitating Central Health Transition of Care referrals. When reviewing referrals, other Central Health programs may be considered and referred to as appropriate, such as Respite. This team member would coordinate care with the interdisciplinary team and the referral source and conduct on site referral screenings at assigned hospitals and/or referral source locations. In addition to coordinating care, this team member would receive and appropriately document all referrals in a timely manner and monitor referral from generation to assignment to a care team. The team member will participate in coordinating care with Nurse leads/supervisor, hospital staff, referral source personal, and patient interdisciplinary team. Transition of Care Clinical Liaison will provide effective communication to patients, staff members, and outside referral partner organizations in a professional and creative manner. This team member will demonstrate commitment, professional growth and competency and promote Central Health's philosophy and administrative policies to ensure excellent quality of care.

*** This is an onsite role ***

Essential Functions:

• Must be able to review submitted referrals from epic workque and obtain the proper information/documentation needed to assess referral eligibility.
• Act as an in person liaison, interfacing with referral sources, outside agencies, health professionals, Transition of Care team, and patients.
• Completes intake screening including obtaining, documenting, and analyzing all required information to make a preliminary assignment decision for patient acceptance or denial and placement.
• Ensure Transition of Care Standard Operating Procedures are followed for all referrals.
• Uphold and complete referrals ensuring entire referral process is complete. Update referral status in epic as appropriate.
• Communicate and collaborate effectively with patients, family members, case manager, healthcare providers, and co-workers.
• Collaborate with all members of the care team in providing person centered care.
• Assist in determining the health status and needs of patients based on interpretation of health related data and preventative health practices. Decides acceptance/denial of patients and coordinates admission process with referral source.
• Obtains accurate information from physicians, patient, referral source regarding the expected discharge plan.
• Exhibit compassion, vulnerability, and empathy when working with employees and patients and advancing Central Health's health equity and DEI goals. Share a commitment to diversite and inclusion awareness and health equity practices across Central Health.
• Update incoming referral post acute spreadsheet as appropriate.
• Discuss Post Acute SNF admission process, expectations and obtain consent from patient for SNF admission.

Knowledge, Skills and Abilities:

• Preferred ability to speak, read, and write the Spanish Language.
• Strong assessment skills
• Utilize clinical skills to review and monitor utilization of health care services with the goal of maintaining high quality cost-effective care whle engaging and empowering the client.
• Shares a commitment to diversity and inclusion awareness and practices across Central Health
• Provides patient-centered care that is inclusive of cultural humility and compassion

Minimum Requirements:

Education:

• High School Diploma or Equivalent
• Graduated from an accredited school of Vocational School of Nursing LVN/LPN

Work Experience:

3-5 years of relevant clinical experience working in a hospital or community based clinical setting.

Licenses/Certifications:

• Licensed Vocational Nurse in the State of Texas (LVN/LPN)
• Basic Life Support (BLS)-Obtained through approved American Heart Association