The RN Embedded Care Liaison manages and coordinates patient care within the assigned hospital, ensuring a seamless, efficient, high-quality patient experience aligned with organizational goals. Onsite a minimum of 6 hours daily, this role conducts face-to-face bedside visits in the ER and on units — assessing needs, identifying discharge barriers, scheduling appointments, and facilitating communication across providers to ensure patients receive medically appropriate care throughout their journey. The role also drives pilot and performance-focused initiatives aimed at reducing medically inappropriate readmissions and post-acute SNF/rehab placements, partnering with the hospital and PCP office to build safe, appropriate discharge plans and identify high-quality post-acute resources.
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Meet with patient daily at bedside in the ER and/or on units; forge a trusting connection and show value.
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Review EMR and/or care management platform daily to identify hospital admissions and discharges for assigned patients, providing timely updates to the internal team and patient’s PCP, including weekly summary reporting.
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Attend meetings and collaborate routinely with the interdisciplinary team to coordinate medically appropriate services, resources, and discharge planning — including preferred providers and appointments for next site of care — documenting all coordination in the established EMR or care management platform.
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Ensure timely follow-up appointments are scheduled and maintained prior to and at discharge.
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Assess for and communicate clinically relevant patient information to the hospital team, PCP and/or designee in a timely manner.
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Identify clinical concerns of disease progression, assess for medication issues, and/or risk for readmission and escalate accordingly.
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Educate and advocate for patients on available resources, self-management materials, and high-quality next-site-of-care options, connecting them to community resources and Social Work support as needed.
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Utilize, interpret and deliver data-driven decision-making to drive clinical outcomes
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Identify, address, and document barriers or concerns related to admission, length of stay, discharge planning, or transitions of care, communicating these to the interdisciplinary team and PCP.
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Implement and monitor personalized care plans with patients, families, and providers, incorporating discharge education and readmission-prevention strategies to reduce medically inappropriate readmissions.
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Maintain accurate patient records and disperse post-discharge documentation (e.g., discharge summaries) to case managers and PCPs.
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Track and report on patient outcomes, quality metrics (e.g., ACR, UAMCC), and program effectiveness as defined by leadership.
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Works collaboratively with partner departments for continuity of patient care and performance improvement.
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Performs other duties as assigned
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Skills and Competencies
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Rigorous critical thinking and clinical skillset; out of the box type of thinking preferred
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Comfortable navigating ambiguous environments
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Excellent time management and prioritization skills
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Proficient with electronic health records, practice management systems, and Microsoft Office (Excel, Word, Access)
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Comfortable utilizing web-based virtual environments (Teams, Zoom, etc.)
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Strong verbal and written communication skills in English
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Collaborative and relationship-oriented, working effectively independently or within a multidisciplinary team
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Self-starter with sharp clinical judgment and strong analytical skills, bringing attention to detail and resourcefulness to execute projects in a fast-paced environment
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Success in this role is defined by established metrics and outcomes
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Education and Experience
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Active, unrestricted RN license required (Associate Degree minimum, BSN preferred); CCM or ACM certification a plus.
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Minimum 3 – 5 years of experience in value-based care, case management or other liaison roles, preferably hospital-based.
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Strong organizational, problem-solving, and interpersonal skills, with a commitment to patient-centered care — including effective communication in difficult or demanding situations.
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Understanding of hospital and provider office dynamics and best practices for communicating with and educating provider staff.
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Experience and ability to operate within defined performance metrics and targets
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Physical Demands
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On-site at assigned hospital daily (minimum 6 hours) for care coordination efforts
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Ability to maintain day-to-day operational assignments within various environments (onsite, virtual, etc.)
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Additional Information
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Must abide by all HIPAA, Confidentiality & Privacy Laws
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Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job
Skills and Competencies
-
Rigorous critical thinking and clinical skillset; out of the box type of thinking preferred
-
Comfortable navigating ambiguous environments
-
Excellent time management and prioritization skills
-
Proficient with electronic health records, practice management systems, and Microsoft Office (Excel, Word, Access)
-
Comfortable utilizing web-based virtual environments (Teams, Zoom, etc.)
-
Strong verbal and written communication skills in English
-
Collaborative and relationship-oriented, working effectively independently or within a multidisciplinary team
-
Self-starter with sharp clinical judgment and strong analytical skills, bringing attention to detail and resourcefulness to execute projects in a fast-paced environment
-
Success in this role is defined by established metrics and outcomes
Education and Experience
-
Active, unrestricted RN license required (Associate Degree minimum, BSN preferred); CCM or ACM certification a plus.
-
Minimum 3 – 5 years of experience in value-based care, case management or other liaison roles, preferably hospital-based.
-
Strong organizational, problem-solving, and interpersonal skills, with a commitment to patient-centered care — including effective communication in difficult or demanding situations.
-
Understanding of hospital and provider office dynamics and best practices for communicating with and educating provider staff.
-
Experience and ability to operate within defined performance metrics and targets
Physical Demands
-
On-site at assigned hospital daily (minimum 6 hours) for care coordination efforts
-
Ability to maintain day-to-day operational assignments within various environments (onsite, virtual, etc.)
Additional Information
-
Must abide by all HIPAA, Confidentiality & Privacy Laws
-
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job
