Care Transitions Patient Care Liaison-MSW-FT Days

Care Transitions Patient Care Liaisons coordinate post-acute care appointments and other healthcare services at Mount Sinai Health System facilities and external organizations to fit the specific needs of each patient. They facilitate the transfer of information between the patient and member agencies of the care team to ensure high quality transitions of care across inpatient and outpatient settings. They liaise between medical providers, patients, health insurance companies, and more. Patient Care Liaisons increase health literacy by educating patients on the importance of post-discharge care, preventative screenings and procedures, and chronic disease management. This position promotes a high level of patient satisfaction by identifying and helping to address barriers to high quality, patient-centered care.

1. Facilitates timely access to primary care and specialty appointments by scheduling services related to post-acute care and chronic disease management. This includes addressing barriers to completing care with the patient’s multidisciplinary team.
2. Advocates for patients who need assistance obtaining appropriate medical care. 
3. Uses data reporting tools in the electronic medical record, other hospital information systems, and data provided by health insurance companies to coordinate the right care for the patient at the right time.
4. Serves as a member of the interdisciplinary care team by participating in hospital-based unit rounds to collaborate on the post-acute needs of patients. This includes bedside interactions with inpatients to verify patient information and preferences for post-discharge care.
5. Works with Admitting to ensure accurate and complete electronic medical records by updating patient demographics. 
6. Educates patients in the areas of health promotion, disease prevention, and management of acute/chronic illnesses.
7. Educates providers and practice staff on role of Patient Care Liaison, improvement initiatives, and best practice implementation.
8. Identifies underlying systems problems or obstacles to the delivery of high levels of customer service and participates in continuous process improvement.
9. Participates in quality improvement and quality assurance activities, including creating new workflows.
10. Provides ongoing statistical and financial reporting of all service activities.
11. Participates in the development of other staff members.
12. Directs non-English speaking patients to providers conversant in their preferred language or facilitate the use of translation services.
13. Provides discharge summaries to non-Mount Sinai primary care providers.
14. May be required to perform other duties, including team cross-coverage, when assigned by manager.

• Associate?s degree required; Bachelor?s degree preferred
• 3 years in hospital setting with keen knowledge of patient-focused care, knowledge of hospital
• facilities, and policies and procedures
• High proficiency in computer systems, especially Epic
• Fluency in Spanish strongly preferred

Non-Bargaining Unit, RBE - CARE TRANSITIONS AND POPULATION HEALTH - WST, Mount Sinai West