Ambulatory Care Coordinator

5 days ago


Fort Wayne, Indiana, United States DeKalb Health Full time
Job Summary

We are seeking a highly skilled Ambulatory Nurse Navigator to join our team at DeKalb Health. As a key member of our care team, you will play a vital role in promoting the overall health and well-being of our patients.

Key Responsibilities
  • Provide care coordination to patients, ensuring seamless transitions between healthcare settings.
  • Identify and manage patient populations with unmet primary or social needs, high risk for readmission, and uncontrolled chronic conditions.
  • Coordinate continuity of patient care and transitional care management services with patients and families.
  • Conduct comprehensive and preventive screenings for patients, including outreach to those with gaps in care.
  • Plan, facilitate, and provide health coaching and disease patient education to encourage patients to become proactive in their plan of care.
  • Ensure applicable patients receive annual physical exams and/or annual health risk assessments, including completion of required documentation.
  • Facilitate discussion with patients and family members on advanced care planning directives and services, when appropriate.
  • Help identify workflow and operational opportunities for better patient care, integrating into the clinic as a valued member of the care team.
Requirements
  • Must have an Associate of Science in Nursing (ASN) from an accredited program; Bachelor of Science in Nursing (BSN) preferred.
  • Valid Indiana Registered Nursing License and current BLS certification required.
  • Minimum of 3 years of experience in ambulatory care or hospital setting preferred.
Why Join Our Team?

At DeKalb Health, we offer a comprehensive benefits package, including health benefits, paid time off, employee assistance, community vendor discounts, and payroll deduction options. We are committed to providing excellent care to each patient within our clinics and medical practices, and we believe that our care team members are the key to our success.



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