RN Nurse Care Coordinator

About the Organization The South Side Healthy Community Organization (SSHCO) is non-profit organization built as a collaborative of 13 healthcare organizations - safety net hospitals, health systems and Federally Qualified Health Centers - on the South Side of Chicago. Supported by generous state funding, the SSHCO aims to build a healthcare system that will prioritize community needs, intervene earlier, and respond better. Our model, driven by community input, will better connect existing health organizations, increase access to care, address some of the most challenging health issues we face, and ultimately, build health equity and ensure stronger, healthier communities across the South Side of Chicago.We offer a comprehensive benefits package that includes, medical/dental/vision insurances, 401(k) with company match, paid time off, tuition benefits, company paid life insurance and much more... Req Number CAR-24-00032 Category Care Coordination Position RN Nurse Care Coordinator Open Date 5/31/2024 Exempt/Non-Exempt Non-Exempt Pay Range 41.00 - 48.00 per hour Full-Time/Part-Time Full-Time Work Modality Onsite with occasional traveling work Shift Days Description The RN Nurse Care Coordinator provides experience and expertise to the SSHCO model of care while acting as a patient advocate.ESSENTIAL JOB FUNCTIONS:To perform this job successfully, an individual must be able to perform each essential job function satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties. Identifies, tracks, and manages care for the highest-risk patients in the population. Conducts initial care coordination screening to assess eligibility and performs comprehensive risk assessments. Provide clinical oversight of patient care plan development and implementation by LPN Nurse Care Coordinators. Participates in initiatives, pilots, and other Care Coordination programs. Manages special member populations within the various care models. Performs timely and individualized care coordination to address patients' unique healthcare needs and optimize health outcomes. Collaborates with a multidisciplinary team including primary care physicians, medical directors, specialists, social workers, and other relevant healthcare professionals to leverage their expertise and optimize patient care. Facilitates collaboration between staff, patients, families, and Chicagoland community and state agencies to develop comprehensive care plans for patients managing chronic conditions. Proactively addresses patient/provider concerns and escalates complex issues to the Care Coordination leadership team as needed. Develops patient care plans that integrate mutual goals with the patient, family, provider's emergency plan, medical summary, and ongoing action plan. Adapts communication and care approaches to address individual patient needs, considering health literacy, cognitive or physical limitations, cultural background, and preferred language. Utilizes clear, concise language and multiple communication methods to overcome barriers and ensure patient understanding. Closely monitors patient adherence to the care plan and tracks progress towards established goals. Facilitates adjustments to the plan or escalates concerns to the care team as needed. Actively participates in and champions all patient safety initiatives relevant to the role and collaborates with designated staff to ensure site-specific initiatives are implemented effectively. Manages a designated patient caseload while demonstrating exceptional flexibility and adaptability in response to evolving priorities. Develops and implements individualized clinical health coaching programs to empower patients with chronic disease to self-manage their condition and adopt healthy lifestyle habits, reducing their risk of complications. Leads clear and comprehensive communication of the care plan and transition of care plan to the physician, multi-disciplinary team, patient, and family. This includes addressing any teaching needs and promptly escalating clinical concerns. Facilitates ongoing communication by ensuring everyone on the care team and treating clinicians have up-to-date access to and understanding of patient care plans. Manages transition of care documents, identifies, and addresses quality care gaps, and contributes to quality improvement initiatives by adhering to quality standards and participating in performance measurement processes. Triggers medical reviews when necessary and keeps providers informed of any changes to the care plan or identified compliance issues. Collaborates with medical home staff at the clinic site to ensure a team-based approach to patient care. This includes delegating appropriate tasks to Community Health Workers, maximizing team efficiency. Acts as a leader within an interdisciplinary team and delegates appropriate tasks to LPN Nurse Care Coordinators and Community Health Workers. Performs other duties as requested.QUALIFICATIONS: Travel throughout the Chicagoland area is required for this position. The work schedule is typically weekdays from 8:00 AM to 4:30 PM, but some flexibility is needed as occasional weekend or evening work may be required. Experience: NEW GRADS ACCEPTED. 1 or more years' experience working in a clinical setting, outpatient experience and/or experience working in care coordination or home health preferred. Licenses and Certifications: Up-to-date vaccinations as defined by the CDC, including influenza and COVID-19 required. Proof required prior to the start date. RN license registered and current in the State of Illinois required. CPR certification required. Computer Skills: Strong proficiency with an EMR system (e.g., Athena, Epic, Cerner) preferred. Proficiency in Microsoft Office Suite (Excel, Teams, Outlook). Additional: Ability to work in various settings, including home visits, community events, clinics, and hospital partner sites required. Familiarity and/or experience working with Chicago's West Side and/or South Side communities (residents preferred). Thorough knowledge of care coordination principles Excellent customer service, interpersonal, and communication (written and oral) skills. Excellent time management, detail-orientation, accuracy, and organizational skills in a fast-paced environment Open-mindedness and willingness to facilitate and adapt to change. Thrive in a collaborative team environment and able to work independently with minimal supervision. EOE Statement SSHCO is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We provides equal employment opportunities to all employees and applicants without regard to race, color, creed, ancestry, national origin, citizenship, sex or gender (including pregnancy, childbirth, and pregnancy-related conditions), gender identity or expression (including transgender status), sexual orientation, marital status, religion, age, disability, genetic information, service in the military, or any other characteristic protected by applicable federal, state, or local laws and ordinances. Equal employment opportunity applies to all terms and conditions of employment. Our hiring and employment practices are based solely on job-related criteria and qualifications, and we strive to ensure that all employees and applicants are treated with respect, fairness, and without bias. We promote an environment where every team member can thrive, contribute their best, and reach their full potential.If you require reasonable accommodation during the application process or throughout your employment, please contact us at hr@southsidehealthycommunity.org. We are dedicated to providing the necessary support to ensure equal access and opportunities for all individuals.This position is currently accepting applications.