Onsite ACO Nurse Care Liaison - LTC Advocacy

CareConnectMD, Inc.; California; On-site; USD 48,000 - 66,000; Full time

Job summary

CareConnectMD, Inc. in Costa Mesa, CA is seeking an ACO Nurse Care Liaison to coordinate patient-centered care for residents in long-term care facilities within the CCMD ACO program.

The role focuses on connecting patients, families, PCPs, and facility staff to ensure care plans and interventions meet patient preferences. The Nurse Care Liaison will round daily, monitor changes in condition, and collaborate with CCMD resources to develop and monitor individualized care plans and timely

Qualifications

• Active unrestricted RN license (LVN accepted in residing state).
• Current valid state driver’s license and insurance.
• Must be a licensed driver with an automobile that is insured and in good working order.

Responsibilities

• Daily rounds at Long-term Care Facilities.
• Engage patients and families; identify care preferences and conditions; be available during working hours.
• Monitor patient health, risk factors, and transitions of care; coordinate follow-up.
• Collaborate with PCPs, CCMD Medical Director, facility staff, and other professionals to communicate patient needs and support continuity of care.
• Develop and monitor care plans for high-risk patients with CCMD resources; participate in reviews and meetings.
• Support goals-of-care discussions with patients, families and clinical team; follow protocols.

Skills

Patient-Centered Communication

Clinical Acumen

Care Coordination

Independence

Organization

Professionalism

Physical Requirements

Education

Active RN license

Driver’s license

Job description

CareConnectMD, Inc. in Costa Mesa, CA is seeking an ACO Nurse Care Liaison to coordinate patient-centered care for residents in long-term care facilities within the CCMD ACO program.

The role focuses on connecting patients, families, PCPs, and facility staff to ensure care plans and interventions meet patient preferences. The Nurse Care Liaison will round daily, monitor changes in condition, and collaborate with CCMD resources to develop and monitor individualized care plans and timely