Hospital Liaison

Position Summary:

The Hospital Liaison (HL) will connect with assigned admitted patients at the bedside to facilitate transition of care planning to assess their needs and identify any barriers to returning home. The HL will identity and coordinate resources necessary for a safe transition to the community post-acute care admission while working collaboratively with hospital staff and will function as an integrated member of the hospital case management team. The HL will employ a person-centered, interdisciplinary approach in working with the individual, their family, other caregivers, and medical and behavioral health providers. The HL will support patients in connecting to Home and Community based services and manage complex service support needs.


Job Responsibilities and Performance Standards:

  • Support the hospital’s efforts in connecting individuals to Home and Community Based programs and services that support a discharge to the community.
  • Coordinate with hospital staff to ensure a successful transition to home in order to prevent admission to post-acute institutional care.
  • 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 or programs, utilizing a standardized assessment tool.
  • Identify patients who are enrolled in care and service programs such as ASAP, SCO, and VNA to ensure effective care planning and service coordination for a transition home.
  • Arrange a face-to-face visit post discharge to assess the home environment and social supports.


  • Assist with scheduling follow-up medical appointments and ensure transportation or hands-on assistance is available if needed.


  • Coordinate with appropriate medical staff or pharmacy around medication issues and proper medication management by patient.


  • Review “red flags” and when to contact PCP or VNA.


  • Report to the care team any identified issues in the home that may prevent the patient from remaining in the community.


  • Participate in Hospital Care Management team meetings, daily huddles, interdisciplinary rounds, case conferences and other relevant meetings with hospital care management staff.
  • Ensure accurate and timely documentation in accordance with ASAP and hospital regulations.
  • Provide information and trainings for hospital care management staff regarding HCBS alternatives to instructional care as indicated.
  • Attend agency and team meetings.


Professional Standards and Conduct:

  • Collaborative and Responsive: Regularly communicate, follow up, and use a team-driven approach. Respond thoughtfully and promptly to agency needs, requests, and inquiries; identify and build partnerships with key stakeholders. Demonstrates excellent organizational and time management skills to meet various deadlines, ensuring closed-loop communication. Ability to multi-task and maintain flexibility to adapt and adjust workload assignments based on various needs.
  • Communication: Skilled in verbal and written communication, demonstrating the ability to communicate information in various ways to meet diverse styles and cultural backgrounds.
  • Analytical: Critical thinking skills, using logic and reasoning to identify the strengths and opportunities of alternative solutions, conclusions, or approaches to problems.
  • Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings.
  • Commitment: Embodies SCES’s core values and shows great integrity, accountability, and professionalism in all interactions. Aids in furthering SCES’s mission and commitment to an inclusive environment.



  • Bachelor’s degree or Associate’s degree with significant relevant work experience.
  • Two years of experience in assessment, care planning and case management required.
  • Experience working with older adults preferred.
  • Must be knowledgeable and comfortable using Adobe and MS Word, Excel, PowerPoint, SharePoint, and other Microsoft 365 platforms. Experience with Wellsky strongly preferred.
  • Meets both CORI/SORI and public health screening requirements.


Physical Environment:

  • Physical surroundings are comfortable with minimal exposure to injury or hazards.


Social/Psychological Conditions:

  • Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.


Physical Effort:

  • Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
  • Frequently lifts, pulls, pushes, and carries up to 20 lbs.
  • Periodic eye strain and light ear strain.