Care Transitions Liaison - Rn

Summit CityMD

Atlanta, GA, United States
Patient-centered care plans
Social determinants of health
Medication reconciliation
As an extension of the primary care physician’s (PCP) care team, Care Transitions Liaisons partner with a diverse population of patients, primarily meeting with patients in one or more settings such as, in a clinic, home, facility, or other community settings

Job Summary

  • As an extension of the primary care physician’s (PCP) care team, Care Transitions Liaisons partner with a diverse population of patients, primarily meeting with patients in one or more settings such as, in a clinic, home, facility, or other community settings.
  • Care Transitions Liaisons collaborate with PCPs, hospitalists, multidisciplinary Care Management team members and community agencies/services with the overall goal of improving health outcomes and reducing avoidable utilization for complex and high-risk patients.
  • Our team members are essential to our mission to reshape healthcare through the power of connection.

Matching Summary

As an extension of the primary care physician’s (PCP) care team, Care Transitions Liaisons partner with a diverse population of patients, primarily meeting with patients in one or more settings such as, in a clinic, home, facility, or other community settings.

Skills & Requirements

Must-have

  • patient-centered care plans
  • social determinants of health
  • medication reconciliation
  • advance care planning
  • multidisciplinary care teams
  • clinical information reporting

Nice-to-have

  • strength-based approach
  • low ego and humility
  • culturally sensitive coaching
  • service orientation
  • compassionate community

Key Requirements

  • Registered Nurse with unencumbered license in Georgia
  • 3+ years of direct, clinical nursing experience
  • Care management experience preferred
  • Valid driver's license and personal transportation
  • Comfort and efficiency with technology

Work Rights

Not specified

Tailored Resume

Cover Letter