Clinical Liaison
Company: Wellbe Senior Medical
Location: Mount Prospect
Posted on: August 5, 2022
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Job Description:
Job Summary:
The WellBe care model is a Physician Led Advanced Practice
clinician driven geriatric care (care of older adults) team focused
on the care of the frail, poly-chronic, elderly Medicare Advantage
patients. This population is typically underserved and very
challenged with access to care. To address these problems, we have
elected to bring the care to the patient, instead of trying to
bring the patient to the care. Care is provided throughout the
entire continuum of care - from chronic care and urgent care in the
home, to hospital, to skilled nursing facility, to assisted living,
to palliative care, to end of life care. WellBe's
physician/advanced practicing clinician led geriatric care teams'
partner with the patient's primary care physician to provide
concierge level geriatric medical care and social support in the
home as well as delivering and coordinating across the entire care
continuum.
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*General Summary*
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The Clinical 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:
*SKILLS & COMPETENCIES** -*
* Fosters a culture of best demonstrated practices, customer and
peer service-orientation, measurement, performance, accountability,
and continuous improvement
* Manage the Transition of Care Process from admission to
transition home (i.e, admission, discharge planning and
follow-up)
* Monitors active patients across care settings (hospitals and
SNF's)
* Visit facilities (hospital and SNF's on a routine basis)
* Serves as a resource for the patient and their family to help
solidify discharge and treatment plan
* Facilitation and clarification of patient's goals of care with
the facilities and attending physicians
* Assists with discharge planning from Inpatient or Skilled Nursing
settings
* Works collaboratively with the clinical coordinator to ensure
discharge data is appropriately documented and transition of care
visits are scheduled and verified with the patient/family
* Collaborates with Community Medical Director daily to review the
appropriateness of discharge plans
* 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
* Facilitating access for the patients to verify their ancillary
services such as DME, Home Health, OP Rehab are in place and
meeting their needs
* Attends Interdisciplinary Team (IDT) meetings and provides
additional information on patients
* Face of WellBe in the hospital/SNF if physicians cannot be onsite
(e.g., bring in notes, POLST, etc.), patients know them as WellBe,
and they are part of their WellBe program
* Assist physicians with communicating with attending of record
* Arranges family meetings in the SNF and hospital
* Develop relationships in admitting, ED and Case Management
departments in facility setting
* Coordinates with Facility's Case Management and Social Work Teams
on the discharge
* Develops relationships with SNF Administrators
* Obtains access to clinical records in the facility setting, and
reviews and facilitates medical records transfer to WellBe
* May conduct home visits based on community team needs
* Ability to explain the WellBe model and engage new members into
the program
* Other tasks needed to accomplish team's objectives/goals
Job Requirements:
*QUALIFICATIONS** -*
*Educational/ Experience Requirements*:
* Minimum of 5 years as a Licensed Practical Nurse/Licensed
Vocational Nurse Health Plan/ Hospice Liaison experience
preferred.
* LPN/LVN Licensure required.
* Managed Care experience preferred.
*Required Skills and Abilities:*
* Superior interpersonal skills
* Experience charting in EMR skills
* Detail orientation
* Problem solving and thinking autonomously and owning the
solution
* Professional demeanor
* Knowledge of Geriatric Medical Practice/Terminology
* Innovative
* History of successful outcomes or quality-driven practices
* Ethical patient care
* Teamwork/Can-Do Attitude
* Advanced computer skills (ie. Excel filtering and advanced
features, Google/Gmail, etc.)
* Strong communication skills (verbal and written)
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*Travel requirements**:* Travel may be required up to 100%
locally.
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*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
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*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*
Keywords: Wellbe Senior Medical, Mount Prospect , Clinical Liaison, Other , Mount Prospect, Illinois
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