Ambulatory Nurse Care Coordinator Full Time Days

Northwestern Medicine; Lake Forest (IL); On-site; USD 70,000 - 100,000; Full time

Job summary

Northwestern Medicine is seeking an Ambulatory Nurse Care Coordinator to provide patient care support and robust care management coordination in an ambulatory setting. You will act as a liaison between patients, physicians, and the care team to help patients understand their conditions and responsibilities.

You will advocate for patients, identify needs, and coordinate across care settings to ensure high-quality care and smooth transitions.

Qualifications

• Active nursing license in Illinois (RN).
• BSN required or will be obtained within two years of hire.
• 3 years of experience in chronic conditions, care coordination, and patient management.
• Willingness to travel.

Responsibilities

• Advocate for patients in ambulatory settings and assist navigation across care settings.
• Address care coordination needs for high and moderate risk patients.
• Review patient records to identify needs for care coordination.
• Assess and address clinical, psychosocial, or financial barriers to care.
• Collaborate with multidisciplinary team to plan and evaluate care.
• Provide triage with in-depth clinical knowledge in area of expertise.
• Educate patients and families on medical processes, treatments, and health management.
• Ensure timely continuity of care by outreaching post-discharge, coordinating referrals, and facilitating transitions.
• Manage high risk patient cases to minimize readmissions and optimize quality of care.
• Develop care plans aligned with patient goals and values.
• Monitor patient health information to inform providers and care teams.
• Participate in quality and improvement initiatives to enhance care coordination.
• Provide after-hours on-call support for urgent coordination issues.
• Perform other related duties as required.

Skills

Care coordination

Patient advocacy

Education & coaching

Education

Bachelor of Science in Nursing (BSN)

Job description

Description

The Ambulatory Nurse Care Coordinator reflects the mission, vision, and values of NM, 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.

The Ambulatory Nurse Care Coordinator is responsible for providing patient care support services and ensuring high quality of care through education and robust care management coordination services. The Ambulatory Nurse Care Coordinator functions as a liaison between the patient, physician, and clinical support staff and helps the patient understand their medical conditions and health responsibilities.

Responsibilities

• Serves as a patient advocate in an ambulatory setting and assists in navigating across various care settings.
• Addresses the care coordination needs for high and moderate health risk patients as well as assistance with low-risk or new patients.
• Reviews patient records, registries, reports or other encounter or claims data to identify patients who may require care coordination.
• Assesses, documents and addresses clinical, psychosocial, or financial barriers to effective patient care.
• Consults with multidisciplinary team as appropriate to develop, implement and evaluate care for patients and families specific to the area of expertise.
• Provides effective triage care using in-depth clinical knowledge and skills in area of expertise.
• Provides educational support to patient and family members around medical processes, procedures, treatments, medications, and management of health and wellness.
• 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.
• Manages high risk patient cases in order 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 is receiving the highest level of quality care in each setting.
• Develops care plan that addresses patient’s overall health, including health goals with a plan that is in line with patient’s choices and values. Informs patients regarding access to general preventative care practices. Support patient activation of care plan.
• Reviews and maintains patient health information including medical records and other pertinent information that informs provider and care team members about patient’s health and progress of care outcomes.
• 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.
• Provide after regular business hours on-call support for urgent care coordination issues.
• Performs other related duties as directed or required.

Qualifications

Required

• Current license as a Registered Nurse - State of Illinois Professional Nurse.
• Bachelor of Nursing Degree (BSN) with three to five years of relevant clinical experience or BSN required within two years of hire.
• 3 years of experience (5 years preferred)working with chronic conditions, evidence-based medicine,care coordination, care management, and psychosocial and behavioral factors affecting healthoutcomes.
• Willingness to travel (some travel may be required).

Preferred

• 3 years of experience in Care Management or Care Coordination
• Case Management certification preferred or willingness to complete upon meeting eligibility criteria.
• Experience with ambulatory operation and ambulatory nursing care.
• Experience with process improvement.

Equal Opportunity

Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.

Sign-on Bonus Eligibility (if sign-on bonus offered for position):

Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.