ACO Nurse Care Liaison

Job Description

Job Description

Overview of Position

The ACO Nurse Care Liaison coordinates patient-centered care for individuals living in long-term care facilities and participating in CareConnectMD’s (CCMD) Accountable Care Organization (ACO) program. The focus of this role is to connect and communicate with Patients, Families, Primary Care Physicians, and Long-term Care Facility staff. The ACO Nurse Care Liaison will round daily in Long-term Care Facilities to identify clinical needs, monitor care plans and changes in condition, and coordinate individualized care plans and timely interventions. 

The ACO Nurse Care Liaison is supported by a CareConnectMD’s ACO Medical Director, Nurse Practitioner Team, and a Care Coordinator, along with access to medical records and data. The role is instrumental in improving health outcomes, while ensuring Patient preferences are honored.

Candidates must reside locally in Toledo/Sylvania metro area and be able to work onsite daily.

Key Duties and 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.

Education and Experience

• 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.

Essential Skills and Abilities

• Patient-Centered Communication: Communicates with empathy and clarity, including during sensitive conversations involving patients, families, and goals of care.
• Clinical Acumen and Judgment: Has strong clinical knowledge, judgement and assessment skills. Recognizes changes in patient condition, evaluates risk, and identifies appropriate interventions and escalation needs within scope of practice.
• Care Coordination and Problem-Solving: Identifies barriers to care, coordinates resources, and supports continuity of care.
• Independence and Accountability: Committed to the people in their panel. Works independently, prioritizes competing needs, and follows through on responsibilities.
• Organization and Adaptability: Manages multiple priorities, adjusts to changing clinical needs, and maintains accurate, timely documentation.
• Professionalism and Collaboration: Protects confidential information and collaborates effectively with patients, families, providers, facility staff, and internal teams.
• Physical Requirements: Ability to lift and carry up to 20 pounds and perform job-related physical activities, including standing, walking, and bending, as required to perform essential job functions.

License/Certification

• Active unrestricted RN license, LVN/LPN license considered in residing state 
• Current/Valid state driver’s license and insurance
• Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.

To ensure the health and safety of our workforce while doing our part to protect those around us, CareConnectMD is requiring proof of full COVID vaccination for employees as a condition of employment, subject to legally recognized accommodations.