ACO Nurse Care Liaison
About The Position
The ACO Nurse Care Liaison coordinates patient-centered care for individuals living in long-term care facilities and participating in CareConnectMD’s Accountable Care Organization (ACO) program. The role focuses on connecting and communicating 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 liaison is supported by CareConnectMD’s ACO Medical Director, Nurse Practitioner Team, and a Care Coordinator, with access to medical records and data. The position contributes to improved health outcomes while ensuring patient preferences are honored. Candidates must reside in the Woburn, Wakefield, Burlington, or Lexington, Massachusetts area and be able 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 automobile that is insured in accordance with state or organization requirements and in good working order.
- Ability to lift and carry up to 20 pounds and perform job-related physical activities, including standing, walking, and bending, as required to perform essential job functions.
- Must reside in the Woburn, Wakefield, Burlington, or Lexington, Massachusetts area and be able 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.
- 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.
- Patient-centered communication, care coordination, problem-solving, independence, accountability, organization, adaptability, professionalism, and effective collaboration.
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 help them understand conditions, primary care, and healthcare options; 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 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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
