RN Care Coordinator, Internal Medicine, Full Time, First Shift

UC Health (Cincinnati); Cincinnati (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

UC Health (Cincinnati) is seeking an Ambulatory RN - Care Coordinator to ensure seamless, high-quality care in outpatient clinics. The role combines direct patient care (about 60%) with administrative duties and requires collaboration with the interdisciplinary team to optimize patient experience.

The nurse will assess complex and chronic disease patients during visits, develop and execute care plans, educate patients and families, document findings, and support care coordination across

Qualifications

• Utilizes the nursing process for direct patient care and assists staff with assessment, planning, implementation, and evaluation.
• Documents nursing history and assessment and initiates referrals based on patient needs.
• Conduct thorough assessments of patients' health status during clinic visits; reassess as needed.
• Administers medications and performs wound care as needed.
• Maintains accurate, timely nursing documentation per hospital policy.

Responsibilities

• Provide direct patient care in ambulatory visits for complex diseases.
• Develop and implement individualized care plans with other healthcare providers.
• Educate patients and families about health conditions, treatment plans, medications, and self-care.
• Document nursing history and assessment and initiate referrals as needed.
• Perform point-of-care testing to support patient well-being.
• Recruit patients for studies and assist with quality assurance.

Skills

Nursing process

Medication administration

Wound care

Patient education

Assessment & planning

Interdisciplinary teamwork

Documentation accuracy

Job description

The Ambulatory RN - Care Coordinator is a vital member of the healthcare team responsible for ensuring seamless and high-quality care for patients in an ambulatory setting. This role involves both direct patient care and administrative responsibilities, with approximately 60% of time dedicated to patient-facing duties. The RN will support ambulatory physician clinics by seeing patients with complex and chronic disease that require additional support during outpatient visits. They will be involved in working with patients to develop and execute care plans, provide patient education, and work collaboratively with interdisciplinary healthcare team members to optimize patient care and experience.

PATIENT POPULATION - (CLINICAL ONLY):

• Engages in population appropriate communication.
• Has knowledge of growth and development milestones and tasks.
• Gives clear instructions to patients/family regarding treatment.
• Involves family/guardian in the assessment, initial treatment and continuing care of the patient.
• Identifies any physical limitations of the patient and deploys intervention when necessary.
• Recognizes and responds appropriately to patients/families with behavioral health problems.
• Interprets population related data and plans care appropriately.
• Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely.
• Recognizes and responds to signs/symptoms of abuse or neglect.

PATIENT ASSESSMENT & INTERVENTIONS:

• Acts as an expert clinician and role model in providing quality patient care to patients and their families within his/her specialty area.
• Utilizes the nursing process for direct patient care and assists the staff with assessment, planning, implementation, and evaluation of patient care needs.
• Conduct thorough assessments of patients' health status during clinic visits. Reassess and evaluate patient as needed throughout their visit.
• Document nursing history and assessment for assigned patients, initiating referrals based on patient needs.
• Collects basic level and advanced patient data. Monitors for trends that could impact patient health.
• Maintain awareness of comfort and safety needs of patients during their ambulatory appointment starting from the time they arrive to their departure. Assess patient environmental safety continuously.
• Respond to life‑saving techniques based on nursing standards, policies, procedures, and protocol.
• Provide accurate hand‑off report when patients are moved between ambulatory areas and/or between ambulatory and inpatient areas.
• Recognizes and reports changes in patient conditions and abnormal labs or results.
• Perform POC testing assessments as needed to support the patient's clinical well‑being and also patient experience.
• Initiate and implement individualized patient care plans in collaboration with other healthcare providers based on clinical assessments, disease process, and patient's identified psychosocial needs.
• Collaboratively develops and utilizes patient care pathways that ensure consistent quality of care for patients.
• Demonstrates competency in administering medications, perform wound care, and provide other direct nursing interventions as needed.
• Completes nurse visits and documents timely and accurately.
• Assist with minor procedures and diagnostic tests, ensuring patient comfort and safety.
• Monitor patients for changes in condition, report findings to the healthcare team, and adjust care plans accordingly.
• Recruit patients for studies
• Assists and collaborates with staff nurses in quality assurance.
• Meet new patients to introduce self and explain role.
• Demonstrates ability to establish priorities of care based on individual patient assessments and the needs of the patients assigned.
• Demonstrates critical thinking and accountability in evaluating and implementing physician orders.
• Ensures timely nursing documented with exceptional accuracy according to hospital policy and procedures. Real time nursing documentation.
• Maintain positive, professional, and cooperative demeanor throughout all interactions with patients, staff, physicians, and members of management. Maintain a calm demeanor during emergent or challenging behavioral situations with patients.

PATIENT EDUCATION:

• Meets with patients and families to identify educational needs related to health promotion, maintenance, alterations in health status, disease processes, diagnostic testing, and interdisciplinary care within specialty area.
• Educate patients and their families about health conditions, treatment plans, medications, and self‑care techniques.
• Reassess for understanding and re‑educate as needed.
• Apply current nursing literature in teaching techniques and guiding standards of care in patient and family education.
• Serve as a expert patient educator for disease‑based and clinic