Care Transitions Liaison - RN

Summit Health•Atlanta, GA

18h

About The Position

At VillageMD, we're looking for a Care Transitions Liaison to help us transform the way primary care is delivered and how patients are served. As a national leader on the forefront of healthcare, we've partnered with many of today's best primary care physicians. We're equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results. We're creating care that's more accessible. Effective. Efficient. With solutions that are value-based, physician-driven and patient-centered. To accomplish this, we're 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 physician’s (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.

Requirements

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 and assistance to 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
Demonstrates consistently, strong ethics and sound judgement
A low ego and humility; an ability to gain trust through good communication and doing what you say you will do
3+ years of direct, clinical nursing experience
Registered Nurse with an unencumbered license in Georgia required
This is a weekend position – must be available to work four, ten-hour shifts on the weekends (Friday, Saturday, Sunday, Monday)
Valid driver’s 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

Nice To Haves

Care management experience in a primary care or inpatient setting preferred

Responsibilities

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 adherence and 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 PCP’s 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 PCPpractice(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