Ambulatory Nurse Care Coordinator
5 days ago
The Ambulatory Nurse Care Coordinator reflects the mission, vision, and values of Northwestern Memorial Healthcare, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards.
Key Responsibilities- Patient Advocacy: Serves as a patient advocate in an ambulatory setting and assists in navigating across various care settings.
- Care Coordination: Addresses the care coordination needs for high and moderate health risk patients as well as assistance with low-risk or new patients.
- Record Review: Reviews patient records, registries, reports, or other encounter or claims data to identify patients who may require care coordination.
- Barrier Identification: Assesses, documents, and addresses clinical, psychosocial, or financial barriers to effective patient care.
- Collaboration: Consults with a multidisciplinary team as appropriate to develop, implement, and evaluate care for patients and families specific to the area of expertise.
- Triage: Provides effective triage care using in-depth clinical knowledge and skills in the area of expertise.
- Patient Education: Provides educational support to patients and family members around medical processes, procedures, treatments, medications, and management of health and wellness.
- Continuity of Care: Ensures timely continuity of care by proactively outreaching to patients post-discharge, managing referrals, facilitating transitions of care, and coordinating community resources. Collaborates across the continuum with patients' care team members.
- High-Risk Patient Management: Manages high-risk patient cases to minimize readmission rates and help reduce the cost of care. Assists in facilitating care coordination for the patient across the care continuum, ensuring that the patient receives the highest level of quality care in each setting.
- Care Planning: Develops a care plan that addresses patients' overall health, including health goals with a plan that is in line with patients' choices and values. Informs patients regarding access to general preventative care practices. Supports patient activation of care plans.
- Health Information Management: Reviews and maintains patient health information, including medical records and other pertinent information that informs providers and care team members about patients' health and progress of care outcomes.
- Quality Monitoring: Monitors quality of care, as well as patient and physician satisfaction, through follow-up discussions and assessments. Participates in continuous quality, performance, and improvement initiatives to ensure the improvement of care coordination.
- After-Hours Support: Provides after regular business hours on-call support for urgent care coordination issues.
- Current License: Current license as a Registered Nurse - State of Illinois Professional Nurse.
- Education: Bachelor of Nursing Degree (BSN) with three to five years of relevant clinical experience or BSN required within two years of hire.
- Experience: 3 years of experience (5 years preferred) working with chronic conditions, evidence-based medicine, care coordination, care management, and psychosocial and behavioral factors affecting health outcomes.
- Travel: Willingness to travel (some travel may be required).
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