Care Transitions Liaison - RN

Summit Health•Atlanta, GA

About The Position

The Care Transitions Liaison (RN) extends the primary care physician’s care team and supports a diverse population of patients, primarily through face-to-face engagement in clinics, homes, facilities, and other community settings. The role helps patients maintain connection to their primary care provider and supports optimal care experiences, improved health outcomes, and reduced avoidable healthcare utilization, particularly for complex and high-risk patients. The Liaison collaborates with primary care physicians, hospitalists, multidisciplinary care management teams, and community agencies. The role provides holistic assessments of patients’ physical, mental, social, and spiritual needs; develops patient-centered care plans with episodic and longitudinal interventions; and helps mitigate barriers to health. The Liaison also supports safe transitions between care settings, including post-discharge follow-up and coordination with inpatient and outpatient teams. The position involves engaging patients in a variety of settings based on program models and initiatives, documenting clinical interventions in applicable care management and electronic medical record systems, and serving as a preceptor for onboarding care management team members. The workweek is five days and includes weekend coverage on Saturday and Sunday. Community visits require a valid driver’s license and personal transportation.

Requirements

At least 3 years of direct clinical nursing experience.
Registered Nurse with an unencumbered license in Georgia.
Valid driver’s license and personal transportation for community visits.
Comfort and efficiency using technology, including Microsoft suite products.
Experience using electronic health records, including data capture, data mining, and reporting.
Ability to engage diverse populations and provide culturally sensitive coaching, education, and assistance to patients and their families or caregivers.
Service orientation and a can-do attitude.
Strength-based approach to collaborative problem solving.
Ability to receive feedback and apply it to work performance.
Consistently strong ethics and sound judgment.
Humility and ability to build trust through effective communication and follow-through.
Five-day workweek that includes weekend coverage on Saturday and Sunday.

Nice To Haves

Care management experience in a primary care or inpatient setting.

Responsibilities

Engage patients and their support systems at the point of care, assess health and risk status, and establish patient-centered care plans.
Provide early intervention related to condition and lifestyle management, medication adherence, and unmet social determinants of health needs.
Collaborate with inpatient care teams and hospitalists or SNFists to coordinate care and mitigate risk factors before discharge to reduce readmissions.
Promote advance care planning and guide patients through outlining their healthcare wishes.
Coordinate with inpatient and outpatient multidisciplinary teams to support safe transitions of care, including timely post-discharge primary care appointments and social work referrals.
Maintain consistent communication with primary care physicians regarding patients’ admission, discharge, and outpatient status.
Serve as a patient advocate and point of contact to support continuity of care.
Monitor patients transitioning from facilities to home, complete post-discharge follow-up and medication reconciliation, and reduce readmission risk.
Present and report clinical information about medically complex patients during multidisciplinary clinical rounds.
Collaborate with primary care physicians and office staff to identify high-risk patients.
Apply an understanding of population health and clinical management of at-risk patients.
Use motivational interviewing to support patient engagement and outcomes.
Conduct comprehensive assessments to identify risk factors and barriers to care, including medication adherence, social determinants of health, and health literacy.
Develop self-management action plans with patients.
Partner with pharmacy, social work, and payer partners to develop targeted intervention programs for patients with chronic conditions or complex social or behavioral needs.
Identify and address gaps in care across the empaneled population.
Coach patients and caregivers on chronic conditions and self-management, and develop escalation plans for decompensation.
Document clinical interventions promptly in applicable care management and electronic medical record systems.
Develop and maintain effective professional working relationships with assigned primary care practices and hospital systems.
Engage patients in varied settings according to program models and initiatives.
Facilitate positive patient interactions that support care management functions.
Serve as a preceptor for onboarding care management team members.