Care Transition Liaison

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 Nursing Support duties: Provides basic care services to patients, but does not have an RN or LPN license.  Positions in this nursing support work under the direction of physicians, mid-level practitioners, and may work under the direction of registered nurses depending on their unit. 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 roleis 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 thoroughlyidentify the needs of referral sources,demonstrating a clear understanding of how referral sources make decisions andidentifying 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. Bachelor's Degree

2. Valid state issuedDriver’s License. 

3. Two (2) years ofexperience marketing to physicians, long-term care,and assisted living facilities to develop effective relationships and referrals. 

4. If hired prior to 9/28/2026, CPR Certification is required upon hire. If hired after 9/28/2026, BLS Certification is required within thirty (30) days of hire.

Preferred Qualifications: 

1.Massachusetts RN Licensure. 

Hours: Full Time, 40hrs/week, Mon-Fri

Location: Melrose/Malden, MA

Duties and Responsibilities: Theduties and responsibilities listedbeloware intended to describe the general nature of work and are not intended to be an all-inclusive list. Other dutiesand responsibilitiesmay be assigned. 

1.Increases 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 asdetermined by the marketing team. 

3.Provides referring agencies with information on existing andnew 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 asappropriate. 

5.Notifies referring agencies/personnel of patient’s progress at HHF asappropriate. 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 andparticipates 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 HHFproducts lines and services andpromote them asappropriate with the account.  

9.Seeks out opportunities toparticipate or attend in account’s meetings, task forces, clinical teams, etc. where HHFexpertise in post-acute care wouldbenefit 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 andfacilitates home assessment as per policy and presents to intake office tofacilitatetimely andappropriate SOC. 

12.Utilizes assessment skills to complete thorough screening of patient’s referral to HHF asdemonstrated 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 asappropriate 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.Participates in broad based referral development activities of Liaison team to ensure information sharing andfacilitate efforts of entire Liaison Team. 

16.Provides regular feedback to manager/director on referral development in defined territories. 

17.Consistently communicates with andoffers 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 obtainingimportant 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 tofacilitate prompt insurance verification and speed admission process while assuring pre-certification (ifrequired) will be obtained before admission. 

25.Meets face to face with families and patients to promote HHF and tofacilitate the patient/family decision process for services. 

26.Assists intake office in discussing details of the case or in obtainingimportant 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 andmaintains an engaged relationship with account case managers and discharge planners.  

31.Reports corporate compliance concerns to the CEO or Chief Compliance Officerwhen 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.) anddemonstrates compliance with Home Health Foundation policies and procedures. 

36.Grows referrals from assigned accounts and looks for opportunities to develop new accounts in the assigned territory through seeking out andmaintaining relationships with physicians, key leadership, and management staff. 

37.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 employeeis 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 25lbs and occasionally lift and/or move up to 100 lbs. 

3. The employee in this positionfrequently communicates internally and externally. 

4. Must be able to exchangeaccurate information via phone, email and/or in person. 

5. Specific vision abilities apply including close vision, distance vision and ability to adjust focus. 

6.Noise 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 invery busy situations. 

3.Responsible and reliable. 

4.Goodorganizational 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 effectiveproblem-solving skills and good judgement. 

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range:

based on full-time equivalent