Care Transitions Liaison - RN
Care Transitions 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
At VillageMD were looking for a Care Transitions Liaison to help us transform the way primary care isdelivered and how patients are served. As a national leader on the forefront of healthcare weve partnered with many of todays best primary care physicians. Were equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results.
Were creating care thats more accessible. Effective. Efficient. With solutions that are value-based physician-driven and patient-centered. To accomplish this were looking for individuals who share our sense of excellence are ready to embrace change and never settle for the status quo. Individuals who have the confidence to lead but the humility to never stop learning.
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 PCP practice(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 OR LVN/LPN with an unencumbered license to practice required
- 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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