Hybrid - Care Transitions Liaison - RN

shm; Atlanta (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

VillageMD is seeking a Care Transitions Liaison to transform how primary care is delivered and how patients are served. You will collaborate with PCPs, hospitalists, and care management teams to ensure smooth transitions across clinic, home, and community settings.

You will conduct holistic assessments of physical, mental, social, and spiritual needs of patients with complex conditions, develop patient-centered care plans, and support follow-up to reduce readmissions and improve outcomes.

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 management, medication adherence and address unmet social determinants of health needs.
• Collaborate with inpatient care teams to ensure well-coordinated care and mitigate risk factors prior to discharge.
• Promote advance care planning and guide patients through healthcare decision processes.
• Coordinate with multi-disciplinary teams to schedule PCP post-discharge follow up and referrals.
• Maintain communication with PCPs regarding patient admission, discharge and outpatient status.

Job description

About Our Company

We're a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical , Village Medical at Home , Summit Health , CityMD , and Starling Physicians .

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

Job Description

Shift Schedule: Thursday - Monday or Friday - Tuesday

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.

How you can make a difference

• 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 dev