RN Care Coordinator

Overview

The Care Coordinator RN is responsible for providing care management and population health services to patients within the assigned region. Primary target populations include those at high risk and vulnerability at times of transition between care settings. Cross‑continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care across the continuum. Consistently using data analytics to manage the health of populations to improve patient access to care, reduce cost of care, and improve clinical outcomes.

• Certified:
  Licensed Registered Professional Nurse (RN) – Illinois Department of Financial and Professional Regulation (IDFPR)
• Basic Life Support (BLS) within 30 days – American Heart Association (AHA)
• Education:
  
  College Diploma:
  Nursing;
  Bachelor’s Degree:
  Nursing
• Work Experience:
  
  2+ years nursing

• Conduct in‑depth assessments of patient/family needs, coordinate input from all health professionals, and formulate documented plans to assure continuity of care for at‑risk patient populations. Include health risks assessment, patient preferences and goals, health literacy, patient engagement, confidence for self‑management, impact of chronic conditions and comorbidities, and social determinants of health.
• Delegate care based on situation, assume accountability for patient outcomes, serve as resource, hold care team accountable, develop shared care plan in Common Care Plan, perform outreach to engage appropriate patients.
• Advance Care Planning: connect patients and surrogate decision makers to ACP facilitation, ensure ACP documents stored and available in the EHR.
• Medication Management: reconcile discharge medication orders, specialist and PCP orders; collaborate with PCP/interdisciplinary team on medication changes; ensure patient understanding and explain discontinuations.
• Psycho‑social support: identify complex behavioral or social needs, refer to social workers, behavioral health consultants, community agencies; coordinate interdisciplinary treatment team to evaluate progress, identify barriers, and improve care.
• Coordinate and manage transitions across continuum, ensure appropriate utilization of clinical and community resources.
• Coordinate referral processes from PCP to specialty; oversee transition to SNF, monitor patient progress; complete post‑SNF transition plan, schedule post‑discharge call and PCP follow‑up; coordinate access to specialists, homecare, palliative, hospice, and other community services.
• Initiate post‑transition phone calls to high‑risk/high‑vulnerability patients to assess self‑management and risk of readmission.
• Participate in quality improvement processes: readmission root cause analysis, ED and inpatient hospitalization utilization reduction and mitigation efforts.
• Collaborate with IP team to align resources and support systems for successful transition to outpatient settings, ensuring warm hand‑off communication.
• Patient education: assess patient/family knowledge and confidence in chronic disease self‑management, provide resources, reinforce education, facilitate Teach‑back methodology, empower patients to appropriately use healthcare resources.
• Data analytics: identify appropriate risk stratification via EHR encounters or datasets, integrate patient registry, stratification, and tools/reports to target patients for care management.
• Manage revolving patient panel of 100‑125 patients, including those with multiple comorbidities, high ED utilization, or high risk for admission or readmission.
• Assist in developing care management tools for patient population.
• Build collaborative partnerships with primary care providers and interdisciplinary team members across the continuum to create individualized plans of care.
• Perform telephonic and in‑person touchpoints with paneled patients to ensure compliance and understanding of plan of care.

The compensation range for this position is $30.39 per hour - $52.27 per hour. This represents a good‑faith minimum and maximum range for the role at the time of posting by Carle Health. The actual…