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, and coordinate individualized care plans and timely interventions. The position is supported by the ACO Medical Director, Nurse Practitioner Team, a Care Coordinator, and access to medical records and data. It contributes to improved health outcomes while ensuring patient preferences are honored. Candidates must be local to Quincy, Milton, or Dedham, Massachusetts, and available to work onsite.
Requirements
- Active, unrestricted RN license; an LVN license is considered in the residing state.
- Current, valid state driver’s license and insurance.
- Licensed driver with an insured automobile in good working order, meeting state or organizational requirements.
- Experience using electronic medical records and Microsoft Office applications.
- Strong clinical knowledge, judgment, and assessment skills; ability to recognize changes in patient condition, evaluate risk, and identify appropriate interventions and escalation needs within scope of practice.
- Ability to communicate with empathy and clarity, including during sensitive conversations involving patients, families, and goals of care.
- Ability to identify barriers to care, coordinate resources, and support continuity of care.
- Ability to work independently, prioritize competing needs, and follow through on responsibilities.
- Ability to manage multiple priorities, adapt to changing clinical needs, and maintain accurate, timely documentation.
- Ability to protect confidential information and collaborate effectively with patients, families, providers, facility staff, and internal teams.
- Ability to lift and carry up to 20 pounds and perform job-related activities including standing, walking, and bending.
- Must be local to Quincy, Milton, or Dedham, Massachusetts, and available to work onsite.
- Proof of full COVID vaccination is required 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.
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 early intervention opportunities; 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.
- 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 a variety of sources and maintain accurate, timely documentation in accordance with organizational policies, regulations, and program requirements.
- Participate in new facility onboarding 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
