Care Transitions Liaison (RN/LPN) at VillageMD
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.
As a Care Transitions Liaison at VillageMD, you will work with patients at the bedside/telephonically who are being evaluated for discharge from the hospital. As a new member of the team, you will use critical assessment skills to coordinate care, while encouraging patients to adhere to visits with care team members following discharge.
Could this be you?
A Care Transitions Liaison will empower patients with education on how to self-manage their disease processes, assist patients with maintaining a high quality of life, coordinate care the decrease the risk of readmission and future utilizations events which ultimately improve patients quality of life and decreased unnecessary healthcare spend/cost.
How you can make a difference
- Meet with patients at bedside/telephonically to review current treatment plan and address potential clinical needs
- Collaborate with inpatient care team to ensure patient is receiving optimal inpatient care services, is educated on condition management risk factors and barriers to discharge have been mitigated
- Monitor medically complex patients for presentation during multidisciplinary clinical rounds
- Collaborate with the discharge planners in the hospital to ensure a seamless transition
- Coordinate with inpatient, multi-disciplinary care team in preparation for discharge
- Evaluate patient discharge plans and address gaps in care
- Schedule post-discharge follow up appointment with PCP at bedside
- Enroll patients in care management program for seamless transition from hospital to home
- Serve as a patient advocate and point of contact to ensure continuity of care
- Ensure each patient receives accurate information and education regarding their disease management
Skills for success
- The ability to be flexible in an ambiguous and dynamic environment
- A service-oriented, “can do” attitude
- A willingness to learn on your own and take initiative
- Demonstrates honesty and following through on commitments
- The ability to problem-solve on the spot and identify issues that need escalated
- Achieves objectives by effectively managing multiple tasks at one time
- Maintaining an organized and systematic workflow that results in goals being met
- Adapting quickly to changes, all while maintaining a positive attitude
- A low ego and humility; an ability to gain trust through good communication
What you might do in your first year:
- Train and become knowledgeable in the EMR system(s) that our partner practices use to become the expert and ensure that we have consistency in data and reporting
- Communicate and collaborate with physicians and other health care team members regarding care gaps and future needs of the patient population
- Develop and foster highly collaborative relationships with hospital staff and VillageMD’s multi-disciplinary care team
- Gain a broad understanding of the care model at VillageMD in order to facilitate a positive experience for patients, families, and caregivers
Experience to drive change
- 5+ years of direct, clinical nursing experience
- Registered Nurse or Licensed Practical Nurse with current GA license
- Experience in discharge planning/transitional care management within a healthcare setting
- Experience working for a health plan and/or hospital highly preferred
- Comfort with technology including Microsoft suite office products
- Utilizing a variety of electronic medical records (Epic/Athena) including data capture, data mining and reporting
How you will thrive
In addition to competitive salaries, a 401k program with company match, and a valuable health benefits package, VillageMD offers paid parental leave, pre-tax savings on commuter expenses, and generous paid time off. You work in a highly-collaborative, conscientious, forward-thinking environment that welcomes your experience and enables you to make a significant impact from Day 1.
Most importantly, you make a difference. You see a clear connection between your daily work on VillageMD products and services and the advancement of innovative solutions and improved quality of healthcare for providers and patients.
Our unique VillageMD culture – how inclusion and diversity make the difference
At VillageMD, we see diversity and inclusion as a source of strength in transforming healthcare. We believe building trust and innovation are best achieved through diverse perspectives. To us, acceptance and respect are rooted in an understanding that people do not experience things in the same way, including our healthcare system. Individuals seeking employment at VillageMD are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.