Transitional Care Liaison

Why WellBe?

WellBe’s Culture is Welcoming

• Be part of something important:
• Be part of pioneering a new way of healthcare that is revolutionizing the industry. 
• A patient-focused environment that ensures patients can live a fulfilling life whatever their health level is. Our focus is to give our patients more good days.
• Give yourself incredible opportunities:
• Growth and development opportunities across expanding markets in the company and celebrate success on a global scale.
• Training in the WellBe model and team-based care. Full in-person orientation, vision, mission, and values introduction, and instilling cultural ideals. Respect and trust for how you work and how you make a difference.
• Work as part of a collaborative team with a strong team culture.
• You own your role, contribute to the team, and feel the enormous impact on lives.
• Leadership that listens, trusts, empowers, and supports.
• Empowerment and ownership for solving problems that arise and doing the right thing in each interaction.
• Pioneering a new way of healthcare that is revolutionizing the industry.  

What we offer: 

• Full-time permanent, work seeing patients in their home, traveling around to other home locations.  Work during the daytime, flexible schedule, and on-call rotation.
• Rich and competitive total rewards package including health benefits, dental, vision, life insurance, dependent care reimbursement, STD/LTD, 401k match with immediate vesting, paid time off / floating holidays, commuter/transportation (mileage) reimbursement, and educational reimbursement.
• The opportunity to work with a progressive company, who is making a difference each day with every patient. .

About the Position:

The Transitional Care Liaison is responsible for managing the ongoing hospital census of WellBe's patients. This candidate will help educate patients about WellBe’s program, close gaps in communication between patients and attending physician, and coordinate smooth transitions post-discharge. This candidate will also be responsible for care coordination needs and supporting WellBe clinicians and Community Medical Director (CMD) with operational and clinical tasks.

Job Description

• Fosters a culture of best demonstrated practices, customer and peer service-orientation, measurement, performance, accountability, and continuous improvement.
• Engages in conversations with eligible patients and their families, providing a thorough explanation of the WellBe program and its comprehensive care model, aiming to obtain their consent to participate.
• Review EMR Hospital Census to identify high-priority facilities and patients for in-person visits.
• Conduct patient visits, focusing on:
  • Hospitals: Concentrate on high-density hospitals and those with established relationships with WellBe.
  • High-risk/complex patients: Including patients with high utilization, readmissions, and complex needs.
  • Skilled Nursing Facility: Prioritize high-density SNFs and those with established relationships with WellBe.
• Build strong relationships with key facilities, including hospitals and SNFs, to facilitate effective collaboration and coordination of care.
• Collaborate with Advanced Practice Providers (APPs) and Care Medical Directors (CMDs):
  • Escalate any patient concerns, including barriers to discharge or post-discharge needs, to the appropriate APP/CMD for timely resolution.
• Coordinate with Transitional Care Coordinator (TCC) to coordinate efforts related to high-priority facilities and patients.
• Collaborate with the TCC to schedule post-discharge appointments and retrieve medical records for patients.
• Serves as a resource for the patient and their family to help solidify discharge and treatment plan attends Interdisciplinary Team (IDT) meetings
• Collaborates with Community Medical Director daily to review the appropriateness of discharge plans and
• Reviews with the CMD the medical necessity of Home Health orders, orders for DME, and follows up with those HH agencies and DME agencies on their treatment plan
• May conduct home visits based on community team needs
• Other tasks needed to accomplish team’s objectives/goals

Job Requirements

Must Haves:

Educational/ Experience Requirements:

• Minimum of 5 years as a Licensed Practical Nurse, Certified Medial Assistant, Hospice liaison, Bachelor’s degree or trained Community Health Worker
• Managed Care experience preferred.

Required Skills and Abilities:

• Proficiency in geriatric communication
  • Ability to effectively communicate with older adults, including understanding their unique communication needs, addressing cognitive impairments or sensory deficits, and using age-appropriate language and explanations.
• Critical thinking skills
  • Candidate must demonstrate strong critical thinking abilities. This involves analyzing complex situations, evaluating different perspectives, and making informed decisions
• EMR documentation experience preferred
  • Proficiency in using EMR software allows for efficient and accurate documentation of patient information, treatment plans, and medical histories.
• High level of professionalism 
  • Adhering to ethical standards, maintaining patient confidentiality, and demonstrating integrity in their interactions with colleagues, patients, and their families.
• Strong customer centric focus/service skills
  • The candidate should possess exceptional customer service skills with a focus on the patient experience. They should be empathetic, compassionate, and able to effectively communicate with patients and their families.

Travel requirements: Travel may be required up 0% locally.

Work Conditions:

Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs. Ability to stand for extended periods. Ability to drive to patient locations (ie. home, hospital, SNF, etc). Fine motor skills/Visual acuity

WellBe Senior Medical is an equal opportunity employer. We embrace diversity, inclusion, and equity and encourage all interested readers to apply at wellbeseniormedical.com/careers.

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, change, or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.