RN Embedded Care Liaison - Wellington Regional Medical Center, Wellington, FL

Job Summary 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.

Essential Job Functions Meet with patient daily at bedside in the ER and/or on units; forge a trusting connection and show value.

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.

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.

Ensure timely follow-up appointments are scheduled and maintained prior to and ess for and communicate clinically relevant patient information to the hospital team, PCP and/or designee in a timely manner.

Identify clinical concerns of disease progression, assess for medication issues, and/or risk for readmission and escalate accordingly.

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.

Utilize, interpret and deliver data-driven decision-making to drive clinical outcomes

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.Implement and monitor personalized care plans with patients, families, and providers, incorporating discharge education and readmission-prevention strategies to reduce medically inappropriate readmissions.

Maintain accurate patient records and disperse post-discharge documentation (e.g., discharge summaries) to case managers and PCPs.Track and report on patient outcomes, quality metrics (e.g., ACR, UAMCC), and program effectiveness as defined by leadership.

Works collaboratively with partner departments for continuity of patient care and performance improvement.

Performs other duties as assigned

Qualifications

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…