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

Job Details:

Job Location:

Legal Address - JUPITER, FL 33458, Position Type:
Full Time, Education Level: 2 Year Degree, Salary Range: $90,000.00 - $ Salary, Travel Percentage:
Negligible, Job Category:
Health Care,

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.

• 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 at discharge.
• Assess 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 escalates 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, duration 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.

• 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…