Geriatric Care Coordination Nurse (ACO Liaison)

CareConnectMD, Inc.; Costa Mesa (CA); On-site; USD 48,000 - 66,000; Full time

Job summary

CareConnectMD, Inc. is seeking an ACO Nurse Care Liaison to coordinate patient-centered care for residents in long-term care facilities participating in the CCMD ACO program. You will connect with patients, families, PCPs, and facility staff to align care plans and timely interventions.

The role requires daily on-site rounds in Costa Mesa, CA, with collaboration from the Medical Director, NP team, and care coordinators to improve outcomes while honoring patient preferences.

Qualifications

• Experience in hospital intensive care, telemetry units or emergency departments preferred.
• Experience in a long-term care setting a plus.
• Experience working with frail, medically complex geriatric patients.
• Two years of experience in healthcare case management a plus.
• Knowledge medical necessity, discharge planning, and care coordination a plus.
• Experience using electronic medical records and Microsoft Office applications.

Responsibilities

• Daily rounds at assigned Long-term Care Facilities.
• Engage patients and families; liaise to identify care preferences and options.
• Monitor patient health and changes in condition; coordinate follow-up.
• Collaborate with PCPs, Medical Director, facility staff to communicate patient needs.
• Develop and monitor care plans for high-risk patients; participate in reviews.
• Support goals-of-care discussions with patients, families, and clinical team.
• Gather and review medical records and maintain timely documentation.
• Onboard new facilities and build relationships among CCMD, PCPs and staff.
• Perform other duties as assigned.

Skills

Patient-Centered

Clinical Judgement

Care Coordination

Independence

Organization

Professionalism

Physical Ability

Education

Registered Nurse License

Tools

Electronic Medical Records

Microsoft Office

Job description

CareConnectMD, Inc. is seeking an ACO Nurse Care Liaison to coordinate patient-centered care for residents in long-term care facilities participating in the CCMD ACO program. You will connect with patients, families, PCPs, and facility staff to align care plans and timely interventions.

The role requires daily on-site rounds in Costa Mesa, CA, with collaboration from the Medical Director, NP team, and care coordinators to improve outcomes while honoring patient preferences.