Care Transitions Liaison RN
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Job Location:
Atlanta, GA - USA
Monthly Salary:
Not Disclosed
Posted on:
22 hours ago
Vacancies:
1 Vacancy
Job Summary
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
Shift Schedule: 4 10s Friday Saturday Sunday and Monday
At VillageMDwerelooking 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 healthcarewevepartnered with many of todays best primary care physicians.Wereequipping themwith the latest digital tools. Empowering them with proven strategies and support. Inspiring them with betterpracticesand consistent results.
Werecreating carethatsmore accessible. Effective. Efficient. With solutions that are value-based physician-drivenand patient-centered. Toaccomplishthiswerelooking 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 havean optimalcare experience andmaintainconnection 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 avoidableutilizationfor 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 relationshipsassistin mitigating barriers to healthdecreaseunnecessary healthcare spend/cost andreducefutureutilizationevents.
How you can make a difference
Engage patients and their support systems at the point of care assessing health and risk status andestablishingpatient 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/SNFistto 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 oftimelyPCP post-discharge follow up appointments and referrals to social work
Maintain consistent communication with the PCP related topatientsadmissiondischargeand 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 reducingpatientsoverall 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 inidentifyinghigh-risk patients
Maintain a core understanding of population health and the clinical management of at-risk patients
Employ motivational interviewing skills to elicitoptimalpatient engagement/outcomes
Perform comprehensiveassessmentsidentifyingrisk factors and addressing barriers to care such as medication adherence SDOHfactorsand health literacy.
Able to develop self-management action plans with patients
Partner with VMD Pharmacy SocialWorkand payer partners to develop focused interventional programs for patients with chronic conditions or complex social or behavioral needs
Identifyand 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 plansin the event ofa decompensation
Completetimelydocumentation of clinical interventions in applicable care management and EMR systems
Develop andmaintaineffective professional working relationships with assignedPCPpractice(s) and hospital systems
Engage patients in a variety of settingsdeterminedby 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
A passion for changing the way healthcare is delivered and experienced for complex and/or disadvantaged patients and communities
Ability to engage diverse populations (age ethnic groups socio-economic levels etc.) and provide culturally sensitive coaching education andassistanceto members and their families/caregivers
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
Demonstratesconsistently strong ethics and sound judgement
A low ego and humility; an ability to gain trust throughgood communicationand doing what you say you will do
Experience to drive change
3 years of direct clinical nursing experience
Registered Nurse with an unencumbered license inGeorgia
Care management experience in a primary care or inpatient setting preferred
This isa weekend position must be available to workfour ten-hour shifts on the weekends (Friday Saturday Sunday Monday)
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 dataminingand 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
Key Skills
About Company
Summit Health has more than 2,500 providers, 12,000 employees, and over 340 locations in New Jersey, New York, Connecticut, Pennsylvania, and Central Oregon. Determine your health needs and choose the provider that best fits your needs.
