Onsite ACO Nurse Care Liaison - Patient-Centric Care

CareConnectMD, Inc.; Boston (MA); On-site; USD 50,000 - 66,000; Full time

Job summary

CareConnectMD, Inc. in Charlestown, MA, seeks an ACO Nurse Care Liaison to coordinate patient-centered care across long-term care facilities within our ACO program. You will engage patients, families, PCPs, and facility staff, round daily in facilities, and help develop individualized care plans.

Onsite work is required for local candidates. Ideal candidates reside in the Woburn, Wakefield, Burlington, or Lexington, MA area and have RN licensure with strong documentation and collaboration skills

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: Round at assigned Long-term Care Facilities.
• Patient and Family Engagement: Build trusting relationships through communication, education, and advocacy. Liaise to identify their care preferences, and understand their conditions, PCP care, and healthcare options. Be available for calls during working hours.
• Clinical Monitoring and Risk Management: Monitor patient health, risk factors, changes in condition and transitions of care; identify early intervention opportunities; and coordinate risk-based follow-up.
• Provider and Facility Collaboration: Collaborate with PCPs, the CCMD ACO Medical Director, facility staff, and other healthcare professionals to communicate patient needs, reinforce care plans, and support continuity of care.
• Care Planning and Interdisciplinary Collaboration: Partner with the CCMD ACO Medical Director and centralized clinical resources to develop and monitor care plans for high-risk patients. Participate in case reviews and interdisciplinary team meetings.
• Goals of Care and Patient Advocacy: Support goals-of-care discussions with patients, families, and the clinical team to align care with patient preferences and goals. Complete required training and follow established protocols.
• Clinical Documentation and Information Management: Gather and review relevant medical records from a variety of sources and maintain accurate, timely documentation in accordance with organizational policies, regulations, and program requirements.
• Program and Facility Support: Participate in new facility onboarding and establish effective working relationships among CCMD, PCPs, facility staff, and other care partners.
• Other Duties: Perform other duties as assigned, consistent with the position’s scope, qualifications, and organizational needs.

Skills

Patient-Centered Communication

Clinical Acumen

Care Coordination

Independence and Accountability

Organization and Adaptability

Professionalism and Collaboration

Physical Requirements

Job description

CareConnectMD, Inc. in Charlestown, MA, seeks an ACO Nurse Care Liaison to coordinate patient-centered care across long-term care facilities within our ACO program. You will engage patients, families, PCPs, and facility staff, round daily in facilities, and help develop individualized care plans.

Onsite work is required for local candidates. Ideal candidates reside in the Woburn, Wakefield, Burlington, or Lexington, MA area and have RN licensure with strong documentation and collaboration skills