Job description

Position Summary

The Care Coordinator is a Registered Nurse or Registered Social Worker who provides care coordination, medical and disease education, and outreach services to assist patients in navigating health care transitions and supports patient empowerment through health education, advocacy and coaching. The RN Care Coordinator ensures the continuity and quality of care for patients with multiple complex medical conditions, as well as chronic diseases, with goals of self-management. The person in this position provides care coordination with a Triple Aim approach in mind: Improve the patient experience, improve population health and lower the cost of health care.

Core Job Responsibilities

• Serve as team lead for intake process, development and maintenance of care plan and promoting health programs and services.
• Utilize information systems and decision support, manages a patient panel to proactively contact, educate, and track patients by disease, risk, and self-management status, as well as family and community need.
• Lead Patient-Centered Care Planning based upon the nursing process to include assessment, plan,

implementation/intervention and evaluation, as well as a method for monitoring and intervening.

• Conduct home/community visits (face-to-face) according to policy and workflows.
• Provide resources to support patient/families in self-management to meet health care treatment goals, assess readiness to learn and validate learning outcomes.
• Purposefully engage patients and/or families to voice care-related questions and concerns and recognize individual expertise of the patient by coaching and counseling.
• Facilitate pre-planning, patient education and empowerment, and assessment of patient barriers to support the most effective and efficient interactions between patients and providers.
• Work collaboratively with interdisciplinary teams and health care team members both internal and external to the organization to improve patient care through effective utilization and monitoring of health care resources.
• Assist patient and providers from across the care continuum in the transition from outpatient- to inpatient setting, and ensure post-emergency department, hospitalization, and/or specialist follow up.
• Appropriately and in a timely manner, document interactions, findings, and continuum of care-related activities in the electronic medical record to assure optimal patient care reporting on quality improvement efforts.
• Participate in evaluating outcomes at the individual level with each patient/client and at the same time participate in agency-wide evaluative efforts to ensure and improve the overall quality of service being delivered.
• Work collaboratively with the quality department to improve patient outcomes through the review of patient care gaps, educating patients on the importance of prevention care and ongoing needed assessments, remain aware of quality initiatives and ACCESS quality priorities.
• Perform other duties as assigned.

Requirements/Preferences

• Bachelor’s degree required; Master’s degree preferred
• Registered SW or Registered Nurse (RN); current unrestricted licensure in Illinois, required
• A minimum of one (1) year of general nursing experience in a clinical setting is required
• Case management and/or care coordination experience preferred.
• Bilingual Spanish a plus
• Previous experience using an electronic medical record preferred.
• Intermediate proficiency in Microsoft Office products (Word, Excel, PowerPoint).

Competencies/Behaviors

• Customer orientation – Ability to interact with patients with the desire to respond to and meet their needs, requirements and expectations
• Analysis - Ability to easily consume, process, and analyze data; make recommendations as to appropriate data strategies and tactics
• Reporting - Ability to translate data into meaningful information in report and/or presentation formats
• Strategic Thinking - Ability to think strategically level of detail analysis to plan and execute
• Communication - Strong written, oral, and presentation skills; ability to share information that aligns with audience needs
• Cultural competency - experience working in a multi-cultural environment; ability to work with diverse persons, and personalities.
• Emotional Intelligence - exhibits confidence, empathy and respect when communicating with customers (patients), leadership and staff
• Ability to coach and train using written, verbal, and visual methods
• Ability to multitask and meet deadlines, expert attention to detail
• Ability to maintain the confidentiality of records, documents or discussions related to, ACCESS functions.

Working Conditions/Equipment

• Office environment
• Health center environment
• Remote working options; must have a suitable and secure remote working environment
• Local travel between health centers, hospitals and home/community visits is required; mode of transportation

required, if personal vehicle is employed, a current driver’s license and proof of insurance is required

• Ability to sit for up to 4 hours at a time
• Ability to stand for up to 2 hours at a time
• Computer/laptop
• Phone/Fax/Copier/Scanner

We don’t discriminate for any reason. We welcome talent who believes in our mission, drives the organization forward and cares about the value they bring to an organization.

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