Transitional Care Liaison - Home Health & Hospice

Ohio Living Home Health & Hospice - Greater Columbus - Columbus, OH (30+ days ago)3.4

Ohio Living is among the country's leading faith-based, comprehensive resources on aging well. Since 1922, Ohio Living has defined the highest standards of quality of life for adults. Recognized for quality, innovation, and a positive work environment, we are proud of our reputation for consistently exceeding the needs and expectations of those we serve. At Ohio Living, our mission is the heart of our organization.

Our intention is to have employees who are passionate about making their personal mission statement come to life each day at work! Be it through providing healing, eradicating loneliness in older adults, contributing to efficiencies, streamlining processes, being dependable, sparking creativity or something else, the demonstration of HOW you do your job is just as important as WHAT you do in your job.

Alongside our valued employees, we are making a difference throughout the state of Ohio in the lives of those that need healthcare or those embracing the next chapter of their lives. Sustained members of our team demonstrate accountable behavior and share our values of customer service, innovation, integrity, financial stewardship, leadership and care.

At Ohio Living Home Health & Hospice in Greater Columbus, a premier provider of home health and hospice services throughout Delaware, Fairfield, Franklin, Licking, Madison, Morrow, Pickaway, and Union counties, w e provide an engaging, team ‐ oriented workplace dedicated to career, family and faith. We are committed to recognizing our employees for a job well done, supporting employee training and development, and promoting work-life balance and wellness of body, mind and spirit. And depending on an employee's status, we offer affordable medical, dental, and vision insurance, 403b retirement savings, paid time off, education assistance, and much more.

Ohio Living Home Health & Hospice in Greater Columbus was named a bronze Employer of Choice by LeadingAge Ohio for 2017-2018. The award recognizes providers of aging services who demonstrate leadership in employee development and engagement and meet stringent workforce development criteria. Thirty organizations received bronze of which four are Ohio Living life plan communities and four are Ohio Living Home Health & Hospice locations.

Headquartered in Columbus, Ohio Living is one of the nation's largest not-for-profit, multi-site senior living organizations. Each year, Ohio Living serves more than 73,000 people through one of our 12 life plan communities and Ohio Living Home Health & Hospice. Our Ohio-based services range from a variety of housing options in one of our communities through the full continuum of care to post-acute home health and hospice support for adults, wherever they live.

Our mission is to provide adults with caring and quality services toward the enhancement of physical, mental and spiritual well-being consistent with the Christian Gospel. The Transitional Care Liaison is an integral member of the health care team in representing the organization to the greater community of health care providers by marketing the agency services to influencers using a strategic marketing plan for the purpose of generating consistent admissions from physicians, hospitals, and post-acute care providers to maintain a census level and payer mix at or above budget.

Essential Activities and Tasks

Community and Provider Relations

Develop relationships with case managers, social workers and discharge planners to generate and facilitate new referrals.

Meet with patients and/or families to evaluate their need for home health and hospice services.

Obtain pertinent demographic and medical information for writing up referrals so that appropriate care can be initiated upon patient discharge.

Communicate with hospital staff when the organization's clients return to the hospital, either through the ER or for planned admissions to obtain a resumption of care when they are discharged.

Communicate with clinical staff/team managers at our agency about client admissions, expected discharge dates, and any other problems or concerns related to our ability to care for the client.

Meet with clients and families in the hospital setting to explain the organization's services after receiving permission from hospital to follow client.

Discuss agency hospice and private duty services with potential referrals and write up referrals as necessary.


Communicate with key hospital staff when Accountable Care Organization (ACO) beneficiaries are admitted to the hospital to obtain orders for home health care, hospice, or Home to Stay.

Communicate with office clinical staff and team members regarding ACO client admissions, expected discharge dates and other problems or concerns related to our ability to care for the client.

Communicate with ACO beneficiaries' primary care physician offices to obtain timely physician appointments following post hospital discharge.

Quality and Compliance Management

Understand and easily access the company's EMR, as well as other EMR computer systems in multiple healthcare facilities.

Review patient medical information and write up referrals so that appropriate care can be initiated upon patient discharge.

Secure appropriate face to face documentation from discharging physician.

All other duties as assigned.



Bachelor's degree in business, marketing or nursing required; or

Current unencumbered license for the state of Ohio to practice as a Registered Nurse (RN), Licensed Practical Nurse (LPN) required.


Five years experience in nursing required.

Two years experience in a hospital setting required.

Strong knowledge of the full continuum of care and the eligibility requirements for home health, hospice, skilled nursing, and assisted living required.

Proficiency with Windows, Microsoft Office (Word, Excel, PowerPoint), and the internet required.

Other Requirements

Must be able to read, write, speak, and understand the English language.

Must possess a valid driver's license and acceptable driving record. Must be insurable under professional liability and crime coverage policies as specified by insurance carrier underwriting standards.