Heart Failure Nurse Care Coordinator
2 weeks ago
At Emory Healthcare, we are seeking a highly skilled and compassionate Registered Nurse Care Coordinator to join our multidisciplinary Advanced Heart Failure team. As a key member of our team, you will play a vital role in providing exceptional patient care and coordination services to our patients with heart failure.
Job Summary:The Registered Nurse Care Coordinator will serve as the liaison between patients, caregivers, outside agencies, and our multidisciplinary Advanced Heart Failure team. Your primary goal will be to intervene early to prevent hospitalizations by utilizing electronic and telephone communication. You will be responsible for proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient, and readmission visits.
Key Responsibilities:- Proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient, and readmission visits.
- Functions as a clinical liaison, facilitator, advocate, and collaborator in a multidisciplinary care team across the continuum of care to provide complex disease management interventions to high-risk and post-discharged patients identified.
- Conducts targeted outreach to identified patient panels to ensure timely and efficient care delivery across the continuum of care.
- Improve communication and collaboration between patients and families, healthcare teams, and community-based organizations.
- Performs patient re-assessments to determine current health status and progress toward healthcare goals and care plan completion.
- Conducts systematic, ongoing, and criterion-based evaluation of outcomes in care coordination plans of care. Updates patient care plan, as appropriate.
- Ensure care gaps are closed around specialty/chronic diseases. Serve as a primary point of contact for identified high-risk and post-discharged patients and facilitate access to services.
- Partners with other care coordination teams across the Emory Healthcare system and community organizations.
- Assimilates and documents the results of the evaluative processes.
- Applies critical-thinking skills and the use of clinical judgment when implementing population health interventions or planning effective care for groups or individual patients and their families.
- Graduate of an accredited nursing school.
- Bachelor's degree in Nursing (BSN) required.
- Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
- Care Management experience preferred.
- Three (3) years of healthcare experience required.
- BLS Healthcare Provider certifications required.
Emory Healthcare is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet designated ambulatory practice. We are made up of 11 hospitals, 4 Magnet designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.
We are committed to providing equal opportunities and access to all individuals regardless of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression, and/or veteran's status. We respect, value, and celebrate the unique perspectives and backgrounds of all individuals.
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