Care Transition Liaison - RN
Care Transition Liaison - RN
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Job Description
About Our Company
Were a physician-led patient-centric network committed to simplifying health care and bringing a more connected kind of care.
Our primary multispecialty and urgent care providers serve millions of patients in traditional practices patients homes and virtually through VillageMD and our operating companies Village Medical Village Medical at Home Summit Health CityMD and Starling Physicians.
When you join our team you become part of a compassionate community of people who work hard every day to make health care better for are innovating value-based care and leveraging integrated applications population insights and staffing expertise to ensure all patients have access to high-quality connected care services that provide better outcomes at a reduced total cost of care.
Please Note: We will only contact candidates regarding your applications from one of the following domains: @ @ @ @ @ @ or @.
Job Description
Could this be you
As an extension of the primary care physicians (PCP) care team Care Transitions Liaisons partner with a diverse population of patients primarily meeting with patients in one or more settings such as in a clinic home facility or other community settings. Face-to-face engagement with patients ensures our patients have an optimal care experience and maintain connection to their primary care provider. Care Transitions Liaisons collaborate with PCPs hospitalists multidisciplinary Care Management team members and community agencies/services with the overall goal of improving health outcomes and reducing avoidable utilization for complex and high-risk patients. Care Transitions Liaisons provide wholistic assessments including the physical mental social and spiritual needs of patients with complex medical conditions. Through shared decision making Care Transitions Liaisons develop patient-centered care plans with both episodic and longitudinal interventions. These collaborative relationships assist in mitigating barriers to health decrease unnecessary healthcare spend/cost and reduce future utilization events.
How you can make a difference
Engage patients and their support systems at the point of care assessing health and risk status and establishing patient centered care plans
Provide early intervention related to condition/lifestyle management medication adherenceand address any unmet social determinants of health (SDOH) needs
Collaborate with inpatient care team hospitalist/SNFist to ensure patient is receiving well- coordinated care and potential risk factors are mitigated prior to discharge reducing the risk of readmission
Promote advance care planning and navigate patient through process to outline their healthcare wishes
Coordinate with inpatient and outpatient multi-disciplinary care teams to ensure a safe transition of care including scheduling of timely PCP post-discharge follow up appointments and referrals to social work
Maintain consistent communication with the PCP related to patients admission discharge and outpatient status
Serve as a patient advocate and point of contact to ensure continuity of care
Monitor patients as they transition from facilities to home completing post-discharge follow up medication reconciliation reducing patients overall risk of readmission
Able to perform and report clinical information of medically complex patients during multidisciplinary clinical rounds
Actively engage and collaborate with PCPs and office staff in identifying high-risk patients
Maintain a core understanding of population health and the clinical management of at-risk patients
Employ motivational interviewing skills to elicit optimal patient engagement/outcomes
Perform comprehensive assessments identifying risk factors and addressing barriers to care such as medication adherence SDOH factors and health literacy.
Able to develop self-management action plans with patients
Partner with VMD Pharmacy Social Work and payer partners to develop focused interventional programs for patients with chronic conditions or complex social or behavioral needs
Identify and address gaps in care across empaneled population
Leveraging a deep understanding of chronic disease pathophysiology and coincident symptoms/comorbidities coach patients & caregivers on health conditions self-management techniques and develop escalation plans in the event of a decompensation
Complete timely documentation of clinical interventions in applicable care management and EMR systems
Develop and maintain effective professional working relationships with assigned PCPpractice(s) and hospital systems
Engage patients in a variety of settings determined by program models and initiatives
Facilitate positive patient interactions designed to support all care management functions
Serve as a preceptor for onboarding care management team members
Skills for success
Strong Motivational Interviewing and rapport building skills
A passion for changing the way healthcare is delivered and experienced for complex and/or disadvantaged patients and communities
Ability to quickly build trusting relationships by following through on commitments
Agile solution focused problem solving experience
Thrive in a fast-paced environment and can manage competing priorities
A desire for continuous learning that is aligned to updated clinical protocols and best practice recommendations
Strong time management and organizational skills with a demonstrated history of timely documentation and collaboration
The ability to adapt quickly to changing demands in the healthcare industry
A service orientation and a can do attitude
Displays Strength-Based Approach to collaborative problem solving
The ability to receive feedback and apply it to work performance
Demonstrates consistently strong ethics and sound judgement
Ability to engage diverse populations (age ethnic groups socio-economic levels etc.) and provide culturally sensitive coaching education and assistance to members and their families/caregivers
Experience in conflict management and problem resolution
A low ego and humility; an ability to gain trust through good communication and doing what you say you will do
Experience to drive change
3 years of direct clinical nursing experience
Registered Nurse with an unencumbered license in the state of practice
Care management experience in a primary care or inpatient setting preferred
Valid drivers license and personal transportation for community visits
Comfort and efficiency with technology including Microsoft suite of products
Utilizing a variety of electronic health records including data capture data mining and reporting
About Our Commitment
Total Rewards at VillageMD
Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMDs benefit platform includes Medical Dental Life Disability Vision FSA coverages and a 401k savings plan.
Equal Opportunity Employer
Our Companyprovides equal employment opportunities (EEO) to all employees and applicants for employment without regard to and does not discriminate on the basis of race color religion creed gender/sex sexual orientation gender identity and expression (including transgender status) national origin ancestry citizenship status age disability genetic information marital status pregnancy military status veteran status or any other characteristic protected by applicable federal state and local laws.
Safety Disclaimer
OurCompanycares about the safety of our employees and Companydoes not use chat rooms for job searches or Companywill never request personal information via informal chat platforms or unsecure Companywill never ask for money or an exchange of money banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at selectOur Companylocations during regular business hours only. For information on job scams visit file a complaint at
Employment Type
Full-Time
Key Skills
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