RN Nurse Care Coordinator

The RN Nurse Care Coordinator provides experience and expertise to the SSHCO model of care while acting as a patient advocate.

• Identifies, tracks, and manages care for the highest-risk patients in the population.
• Conducts initial care coordination screening to assess eligibility and performs comprehensive risk assessments.
• Provide clinical oversight of patient care plan development and implementation by LPN Nurse Care Coordinators.
• Participates in initiatives, pilots, and other Care Coordination programs.
• Manages special member populations within the various care models.
• Performs timely and individualized care coordination to address patients' unique healthcare needs and optimize health outcomes.
• Collaborates with a multidisciplinary team including primary care physicians, medical directors, specialists, social workers, and other relevant healthcare professionals to leverage their expertise and optimize patient care.
• Facilitates collaboration between staff, patients, families, and Chicagoland community and state agencies to develop comprehensive care plans for patients managing chronic conditions.
• Proactively addresses patient/provider concerns and escalates complex issues to the Care Coordination leadership team as needed.
• Develops patient care plans that integrate mutual goals with the patient, family, provider's emergency plan, medical summary, and ongoing action plan.
• Adapts communication and care approaches to address individual patient needs, considering health literacy, cognitive or physical limitations, cultural background, and preferred language. Utilizes clear, concise language and multiple communication methods to overcome barriers and ensure patient understanding.
• Closely monitors patient adherence to the care plan and tracks progress towards established goals. Facilitates adjustments to the plan or escalates concerns to the care team as needed.
• Actively participates in and champions all patient safety initiatives relevant to the role and collaborates with designated staff to ensure site-specific initiatives are implemented effectively.
• Manages a designated patient caseload while demonstrating exceptional flexibility and adaptability in response to evolving priorities.
• Develops and implements individualized clinical health coaching programs to empower patients with chronic disease to self-manage their condition and adopt healthy lifestyle habits, reducing their risk of complications.
• Leads clear and comprehensive communication of the care plan and transition of care plan to the physician, multi-disciplinary team, patient, and family. This includes addressing any teaching needs and promptly escalating clinical concerns.
• Facilitates ongoing communication by ensuring everyone on the care team and treating clinicians have up-to-date access to and understanding of patient care plans.
• Manages transition of care documents, identifies, and addresses quality care gaps, and contributes to quality improvement initiatives by adhering to quality standards and participating in performance measurement processes.
• Triggers medical reviews when necessary and keeps providers informed of any changes to the care plan or identified compliance issues.
• Collaborates with medical home staff at the clinic site to ensure a team-based approach to patient care. This includes delegating appropriate tasks to Community Health Workers, maximizing team efficiency.
• Acts as a leader within an interdisciplinary team and delegates appropriate tasks to LPN Nurse Care Coordinators and Community Health Workers.
• Performs other duties as requested.

• Travel throughout the Chicagoland area is required for this position. The work schedule is typically weekdays from 8:00 AM to 4:30 PM, but some flexibility is needed as occasional weekend or evening work may be required.
• Experience:
  • NEW GRADS ACCEPTED. 1 or more years’ experience working in a clinical setting, outpatient experience and/or experience working in care coordination or home health preferred.
• Licenses and
  
  Certifications:
  • Up-to-date vaccinations as defined by the CDC, including influenza and COVID-19 required. Proof required prior to the start date.
  • RN license registered and current in the State of Illinois required.
  • CPR certification required.
• Computer
  
  Skills:
  • Strong proficiency with an EMR system (e.g., Athena, Epic, Cerner) preferred.
  • Proficiency in Microsoft Office Suite (Excel, Teams, Outlook).
• Additional:
  • Ability to work in various settings, including home visits, community events, clinics, and hospital partner sites required.
  • Familiarity and/or experience working with Chicago's West Side and/or South Side communities (residents preferred).
  • Thorough knowledge of care coordination principles
  • Excellent customer service, interpersonal, and communication (written and oral) skills.
  • Excellent time management, detail-orientation, accuracy, and organizational skills in a fast-paced environment
  • Open-mindedness and willingness to facilitate and adapt to change.
  • Thrive in a collaborative team…