ACO Nurse Care Liaison
About The Position
The ACO Nurse Care Liaison coordinates patient-centered care for people living in long-term care facilities who participate in CareConnectMD’s Accountable Care Organization (ACO) program. The role connects and communicates with patients, families, primary care physicians, and long-term care facility staff. The liaison rounds daily at assigned facilities to identify clinical needs, monitor care plans and changes in condition, coordinate individualized care plans, and support timely interventions. The position is supported by the ACO Medical Director, Nurse Practitioner Team, a Care Coordinator, and access to medical records and data. Its purpose is to improve health outcomes while honoring patient preferences. Candidates must reside locally in the Reseda, California area and be able to work onsite daily. The role requires an active unrestricted RN license; an LVN license may be considered in the residing state. Candidates must have a valid state driver’s license, insurance, and an insured, working automobile. Proof of full COVID vaccination is required as a condition of employment, subject to legally recognized accommodations.
Requirements
- Active, unrestricted RN license; an LVN license may be considered in the residing state.
- Current, valid state driver’s license and insurance.
- Licensed driver with an automobile that is insured in accordance with state or organizational requirements and is in good working order.
- Ability to lift and carry up to 20 pounds and perform job-related physical activities, including standing, walking, and bending.
- Must reside locally in the Reseda, California area and be able to work onsite daily.
- Proof of full COVID vaccination as a condition of employment, subject to legally recognized accommodations.
Nice To Haves
- Experience in hospital intensive care, telemetry units, or emergency departments.
- Experience in a long-term care setting.
- Experience working with frail, medically complex geriatric patients.
- Two years of experience in healthcare case management.
- Knowledge of medical necessity, discharge planning, and care coordination.
- Experience using electronic medical records and Microsoft Office applications.
- Strong clinical knowledge, judgment, and assessment skills, including recognizing changes in patient condition, evaluating risk, and identifying appropriate interventions and escalation needs within scope of practice.
- Patient-centered communication skills, including empathy and clarity during sensitive conversations.
- Care coordination and problem-solving skills, including identifying barriers to care, coordinating resources, and supporting continuity of care.
- Ability to work independently, prioritize competing needs, and follow through on responsibilities.
- Organization and adaptability in managing multiple priorities, changing clinical needs, and timely documentation.
- Professionalism, confidentiality, and effective collaboration with patients, families, providers, facility staff, and internal teams.
Responsibilities
- Round daily at assigned long-term care facilities.
- Build trusting relationships with patients and families through communication, education, and advocacy; identify care preferences and understand patients’ conditions, primary care, and healthcare options; and be available for calls during working hours.
- Monitor patient health, risk factors, changes in condition, and transitions of care; identify opportunities for early intervention; and coordinate risk-based follow-up.
- Collaborate with primary care physicians, the CCMD ACO Medical Director, facility staff, and other healthcare professionals to communicate patient needs, reinforce care plans, and support continuity of care.
- Partner with the CCMD ACO Medical Director and centralized clinical resources to develop and monitor care plans for high-risk patients, and participate in case reviews and interdisciplinary team meetings.
- Support goals-of-care discussions with patients, families, and the clinical team to align care with patient preferences and goals; complete required training and follow established protocols.
- Gather and review relevant medical records from various sources and maintain accurate, timely documentation in accordance with organizational policies, regulations, and program requirements.
- Participate in onboarding new facilities and establish effective working relationships among CCMD, primary care physicians, facility staff, and other care partners.
- Perform other duties as assigned, consistent with the position’s scope, qualifications, and organizational needs.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
