Registered Nurse (RN) Home Care Liaison | Lutheran General Hospital

Advocate Health at Home is seeking an experienced Registered Nurse (RN) to serve as an onsite Home Care Liaison at Lutheran General Hospital. In this critical role, you will partner with physicians, care management teams, patients, and families to coordinate seamless transitions from the hospital setting to home-based care services.

As the face of Advocate Health at Home within the hospital, you will assess patient needs, facilitate referrals, educate patients and providers, and ensure compliance with regulatory and payer requirements. This position is ideal for a clinically strong RN who thrives in a fast-paced environment and is passionate about improving the patient experience beyond discharge.

• Full-time onsite position located at Lutheran General Hospital
• Weekend coverage required
• Participation in holiday rotation, including:
  • One Winter holiday annually
  • One Summer holiday annually

• Evaluate and process referrals for Home Health, Pediatrics, and Infusion Therapy services.
• Assess patients for eligibility and appropriateness for home care services based on clinical and regulatory guidelines.
• Conduct bedside interviews with patients and families to support discharge planning and transition of care.
• Collaborate with hospital care management teams, social workers, discharge planners, physicians, and skilled nursing facilities.
• Ensure physician orders and required documentation are obtained timely and accurately.
• Complete high-risk referral processes and identify potential risk management concerns.
• Initiate interdisciplinary communication and document the initial home care plan.

• Serve as a resource for physicians, patients, families, and hospital staff regarding home care services and Medicare guidelines.
• Educate care teams on available services, including:
  • Home Health
  • Home Infusion
  • Hospice
  • Palliative Care
  • Pediatrics
  • Durable Medical Equipment (DME)
• Train patients and caregivers on select home care equipment and therapies as needed.

• Verify benefits and obtain authorizations when required.
• Maintain knowledge of Medicare, Medicaid, commercial insurance plans, and managed care requirements.
• Obtain Face-to-Face (F2F) documentation for Medicare and Medicaid patients.
• Assist in ensuring accurate reimbursement through complete and compliant referral documentation.

• Participate in interdisciplinary meetings and site-based care planning discussions.
• Support patient satisfaction initiatives and service recovery efforts.
• Partner with colleagues to ensure productivity, continuity of care, and successful patient handoffs.
• Contribute ideas to improve processes, quality, and customer service.
• Participate in training, onboarding, and mentorship of new team members.

• Current Registered Nurse (RN) license.
• 3-4 years of nursing experience.
• Strong understanding of Medicare regulations and home care eligibility requirements.
• Exceptional communication and customer service skills.
• Ability to manage multiple priorities and navigate multiple computer systems simultaneously.
• Critical thinking and problem-solving abilities.

• 1-2 years of home health or home care experience.
• Experience with discharge planning, transitions of care, care coordination, or utilization management.

Responsible for the screening and accurate completion of referrals to ensure patients meet agency admission criteria and comply with state and federal regulations.

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.