Care Transitions Liaison

About Our Company We're a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. Job Description WHY VILLAGE MEDICAL At Village Medical, 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 and Advanced Practice Providers. 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. OUR CULTURE AND VALUES VillageMD is a group of collaborative, entrepreneurial, and smart people who are united in our goal to improve primary care, making a difference in people's lives. Get Stuff Done: We roll up our sleeves and dive into the details, tackling the work at hand with infectious enthusiasm. We're highly accountable for our work and the value we add, inspiring others with our constant ability to deliver results. No challenge is too small or too big. Build Trust: We are humbled by those we serve and the importance of our vision. We invest in relationships with open and honest conversations seeking personal connections. We show respect for others in our words and actions. We do what we say we are going to do. We are knowledgeable, but always take the time to listen and learn. Innovate: Our curiosity is endless, and challenging the status quo is a priority. New approaches are rewarded, and we are always seeking to improve. We know that changing healthcare is hard, and we embrace the challenge. 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 Will Get Things Done: Meet with patients at bedside/telephonically to review current treatment plan and address potential clinical needs Monitor medically complex patients for presentation during multidisciplinary clinical rounds Coordinate with inpatient, multi-disciplinary care team in preparation for discharge Schedule post-discharge follow up appointment with PCP at bedside Enroll patients in care management program for seamless transition from hospital to home How You Will Build Trust: 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 Collaborate with the discharge planners in the hospital to ensure a seamless transition Coordinate with inpatient, multi-disciplinary care team in preparation for discharge Ensure each patient receives accurate information and education regarding their disease management How You Will Innovate: Serve as a patient advocate and point of contact to ensure continuity of care EXPERIENCE TO DRIVE CHANGE 5+ years of direct, clinical nursing experience Registered Nurse with current license in state of practice 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 About Our Commitment Total Rewards at VillageMD Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD's benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan. Equal Opportunity Employer Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws. Safety Disclaimer Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, or file a complaint at