Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Post Acute Clinical Liaison is focused on working with skilled nursing facility and homecare agencies to support the convalescence and recovery of function of patients recently discharged from Yale New Haven Health enterprise hospitals. This is integral to supporting the enterprise? focus on providing comprehensive, high quality, coordinated, and cost-effective care for the patients it serves. Under the auspices of the Center for Population Health, and in close coordination with YNHHS hospitals, the aligned clinician enterprise, and other care management programs, this role provides critical support and accountability for the clinical staff at skilled nursing facilities and facilitates the patient?s transition home and back to their longitudinal clinicians in the community setting. The primary work entails keeping track of patients covered under total-cost of care value arrangements who have been discharged to skilled nursing facilities, ensuring best practices are followed, facilitating triage of clinical issues, and supporting timely transitions of care back to the home setting.
EEO/AA/Disability/Veteran

• 1. Is a key point person for supporting achievement of clinical and rehabilitation objectives for recently hospitalized patients discharged to skilled nursing facilities.
• 1.1 Understands the clinical and operational levers for managing SNF length of stay in a way aligned with a patient?s objective clinical and functional goals.

EDUCATION

Bachelors degree (or equivalent) in a clinical discipline required, Masters degree preferred

EXPERIENCE

Minimum 3 years experience as a front-line nurse or 5 years as a physical therapist, and at least 1 year in a care management/care coordination, quality management, or physical therapy role, with experience in a clinical post-acute setting highly preferred. Experience working and/or collaborating with different post-acute provider types (skilled nursing facilities, hospice facilities, homecare agencies) preferred.

LICENSURE

Must have an maintain an active, unencumbered licensure as a Registered Nurse or physical therapist, in the State of Connecticut required. Certified Case Manager (CCM) or accredited equivalent strongly preferred.

SPECIAL SKILLS

Strategic thinker with experience in a value-based care management environment; care management/utilization review experience with CMSA or ACMA experience preferred. Ability to organize resources and establish priorities. Excellent verbal and written communication skills. Strong interpersonal skills; ability to work effectively at all levels in a collaborative team environment. Knowledge and understanding of relevant clinical workflow, operating systems, policies and procedures. Ability to organize, lead and hold self and others accountable. Ability to delegate effectively. Ability to effectively establish and maintain working relationships with peers and consultants at all levels of the organization. Knowledge of Epic electronic health record and comfort with strong desktop tool usage including Word, Excel, and PowerPoint

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