Hybrid - Care Transitions Liaison - RN
Core
A clinical liaison supporting primary care physicians to manage complex, high-risk patients across clinic, home, and facility settings to improve outcomes and reduce readmissions.
Role type
Senior IC Registered Nurse (Care Transitions)
Builds
Patient-centered care plans, self-management action plans, and coordinated discharge transitions for complex medical conditions.
Domain
Healthcare / Care Management / Primary Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Registered Nurse license, clinical nursing experience, care management, medication reconciliation, social determinants of health assessment, motivational interviewing, EMR documentation, chronic disease management, patient advocacy, multidisciplinary collaboration, community outreach, precepting.
Preferred skills
Primary care or inpatient care management experience, weekend availability, valid driver's license with personal transportation.
Technologies
Microsoft suite, Electronic Health Records (EHR)
Responsibilities
Engage patients and support systems to assess health status and establish care plans; collaborate with hospitalists and inpatient teams to mitigate readmission risks; coordinate safe transitions of care including post-discharge follow-ups; monitor patients transitioning from facilities to home; perform comprehensive assessments addressing physical, mental, social, and spiritual needs; coach patients and caregivers on self-management techniques; document clinical interventions in EMR systems; serve as a preceptor for onboarding team members.
Seniority
Mid-level, hands-on IC