Hospital To Home Liaison

Hospital to Home Liaison

The Hospital to Home Liaison will facilitate transition of admitted patients to a safe discharge into the community to avoid post-acute institutional care and re-admissions.

This is a full-time, non-exempt (35 hour/week) position. We offer a hybrid remote schedule. Our office is located in Malden, MA with ample free parking!

Working at MVES means:

• A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions

• Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills

• Competitive salaries

• Tufts Medical insurance, Delta Dental and VSP Vision insurance effective 1st day of employment

• 403b Retirement Plan with agency contribution after 2 years of employment

• 3 weeks accrued Vacation time

• 3 weeks accrued Sick time

• 13 Paid Holidays

• 30 personal hours

• Flexible scheduling

• Ample free parking

• Tuition reimbursement

• Employee referral bonuses of up to $2,000

With a refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds and a satisfying balance between your work and personal life, why not join the Mystic Valley Elder Services' Team!

Top Key Activities:

• Coordinate resources while working collaboratively with and functioning as a member of the hospital care management team.

• Outreach and connect with patient and family/caregivers at the bedside to initiate person-centered planning.

• Assess the patient's functional, health and income status to determine eligibility and appropriateness for community long term care services during a post discharge face to face visit.

• Identify patients who are enrolled in care and services programs including ASAP, SCO and VNA to ensure effective care planning and service coordination.

• Participate in interdisciplinary case conferences in conjunction with intake team to enroll patients in home care programs based on presumptive eligibility to ensure swift initiation of services post discharge.

Other Activities:

• Participate in Hospital Care Management team meetings, daily huddles, interdisciplinary rounds, case conferences and other relevant meetings with hospital care management staff

• Ensure timely documentation, information exchange, coordination, and integration of care

• Provide information and training for hospital care management staff regarding HCBS alternatives to instructional care as indicated

Qualifications:

• A Bachelors' degree required from an accredited school in Social Work, Psychology, Counseling, Human Development, Nursing, Sociology, Criminal Justice, Public Health, Public Policy, or Gerontology plus at least three years of experience in counseling, casework or case management providing protective or crisis intervention services.

• The ability to manage multiple objectives/projects

• Excellent interpersonal skills with demonstrated ability to communicate across all levels,

• Highly resourceful team player, with the ability to work effectively independently or as a team

• Demonstrates a willingness to take on new tasks with a general attitude that no task is too small, impossible, or cannot be improved

• Expertise in the following platforms: Microsoft Office (Word, Outlook, Teams, Excel, and PowerPoint), Adobe Pro, Zoom and other web-based applications

• Private transportation

Physical Requirements of the Job:

• Ability to lift, push, pull and carry objects weighing up to 25 pounds

• Ability to climb up and down stairs unassisted

• Ability to travel to the community to perform visits at clients' homes

• Work requires regular standing, stooping, and bending

Mystic Valley Elder Services is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.