RN Care Transition Liaison

Company: Tufts Medicine Care at Home
Location: Lowell
Posted on: July 17, 2025

Job Description:

Job Profile Summary ? This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders . In addition, this role focuses on performing the following Home Care Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed . Provides professional nursing care to patients. Requires a nursing license . A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs . The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education . An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience . Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices. Job Overview This role is responsible for generating home health and hospice referrals in designated territory/facility while serving as liaison between the agency, hospitals, nursing homes, physicians, patients and families, and community organizations. The Care Transition Liaison works to thoroughly identify the needs of referral sources, demonstrating a clear understanding of how referral sources make decisions and identifying decision-makers. Collaborating in a cross functional environment, assists with programs and protocols that provide for the delivery of improved home health care services, including performing complete and thorough pre-intake screens as appropriate. Job Description Minimum Qualifications : 1. Massachusetts RN Licensure. 2 . Valid state issued Driver’s License. 3 . Previous experience marketing to physicians, long-term care , and assisted living facilities to develop effective relationships and referrals. Duties and Responsibilities : The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list . Other duties and responsibilities may be assigned. 1. Increase s census through marketing of geographically defined areas and develop specific referrer relationships with potential referrers. 2. Develops specific referrer relationships with hospitals/community in defined geographic areas with primary focus on case management departments or as determined by the marketing team. 3. Provides referring agencies with information on existing and new programs and services by arranging presentations to hospitals and personnel as per marketing plans developed by the marketing team. 4. Schedules educational programs at hospitals in geographically defined areas to be given by Liaison, Program Coordinators, or other HHF staff as appropriate . 5. Notifies referring agencies/personnel of patient’s progress at HHF as appropriate . Delivers/mail all discharge summaries to social workers and discharge planners in defined territory. 6. Achieves business development targets such as conversation ratio of referral to SOC, hospital admission targets, and contacts/evaluations through detailed marketing plans. Supplies data for statistical reports and Assesses implications of data collection and participates in strategic planning. 7. Seeks out opportunities to become a preferred provider or partner for the account rather than solely a vendor. 8. Maintains an on-going, intimate knowledge of all HHF products lines and services and promote them as appropriate with the account. 9. Seeks out opportunities to participate or attend in account’s meetings, task forces, clinical teams, etc. where HHF expertise in post-acute care would benefit the account ( i.e. ACO committees, re-admission groups, leakage management efforts) and would provide HHF a way to strengthen the relationship with the account. Identifies circumstances where it would be appropriate/expected to involve participants representing HHF’s clinical departments in order to add particular expertise or leadership. 10. Understands the competitive landscape in general and the individual competitors for each assigned account. 11. Completes pre-admission screening process and facilitates home assessment as per policy and presents to intake office to facilitate timely and appropriate SOC. 12. Utilizes assessment skills to complete thorough screening of patient’s referral to HHF as demonstrated by the recognition and documentation of patient’s medical stability, rehab potential, rehab tolerance and applicability to accepted standards of HHF. 13. Contacts referring agencies, physicians and families as appropriate with decision of Admissions and decision of insurance companies. 14. Autonomously makes decisions on straight forward assessments at time of screening . Provides case managers with decisions at time of screenings. 15. Participate s in broad based referral development activities of Liaison team to ensure information sharing and facilitate efforts of entire Liaison Team. 16. Provides regular feedback to manager/director on referral development in defined territories. 17. Consistently communicates with and offers assistance when available to team members in neighboring territories. 18. Consistently attends liaison marketing meetings and generates creative ideas and presents them at marketing meetings. 19. Completes referrals in territories outside of primary territory at request of intake, liaison manager and colleagues. 20. Participates in daily operation of Referral Department to assure smooth referral coordination. 21. Assists intake office in discussing details of the case or in obtaining important information . 22. Coordinates admissions and patient flow effectively with intake office and care providers . Keeps all parties informed. 23. Identifies and consistently meets with insurance contacts in each account. Understands the insurer- specific requirements and orientation to HHF. 24. Obtains insurance information on potential patients and forwards appropriately to facilitate prompt insurance verification and speed admission process while assuring pre-certification (if required ) will be obtained before admission. 25. Meets face to face with families and patients to promote HHF and to facilitate the patient/family decision process for services. 26. Assists intake office in discussing details of the case or in obtaining important information . 27. Coordinates admissions and patient flow effectively with intake office and care providers. Keeps all parties informed. 28. Identifies and consistently meets with insurance contacts in each account. Understands the insurer specific requirements and orientation to HHF. 29. Communicates effectively and maintains an engaged relationship with account case managers and discharge planners. 31. Reports corporate compliance concerns to the CEO or Chief Compliance Officer when applicable . 32. Acts autonomously when gathering referrals in other facilities. 33. Serves as the link between the account and HHF care providers. Effectively works to prevent problems and resolves issues if they happen. 34. Actively pursues educational opportunities and shares knowledge fostering professional growth of the department. 35. Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA etc.) and demonstrates compliance with Home Health Foundation policies and procedures. 3 6 . Grows referrals from assigned accounts and looks for opportunities to develop new accounts in the assigned territory through seeking out and maintaining relationships with physicians, key leadership, and management staff. 3 7 . Exhibits leadership qualities by presenting as a positive role model and stimulating cooperation within the department and facilities. Physical Requirements: 1. While performing the duties of this job, the employee is required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. 2. The employee must regularly lift and/or move 25 lbs and occasionally lift and/or move up to 100 lbs. 3. The employee in this position frequently communicates internally and externally. 4. Must be able to exchange accurate information via phone, email and/or in person. 5. Specific vision abilities apply including close vision, distance vision and ability to adjust focus. 6. N oise level in the work environment is usually moderate. 7. May be exposed to weather conditions prevalent at the time. Skills & Abilities: 1 . Excellent interpersonal skills. 2 . Ability to function well in very busy situations. 3 . Responsible and reliable. 4 . Good organizational skills. 5 . Demonstrates excellent communication, organization, problem solving skills and can prioritize many tasks effectively. 6 . A team player with decision-making, process management, planning, tracking follow-through and analytical abilities. 7. Demonstrates effective problem-solving skills and good judgement. Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org .

Keywords: Tufts Medicine Care at Home, Pawtucket , RN Care Transition Liaison, Healthcare , Lowell, Rhode Island