Ambulatory Nurse Care Coordinator Full Time Days

About the role

The Ambulatory Nurse Care Coordinator reflects the mission, vision, and values of Northwestern Medicine, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and regulatory and accreditation standards. This role is responsible for providing patient care support services and ensuring high-quality care through education and robust care management coordination. The Ambulatory Nurse Care Coordinator functions as a liaison between the patient, physician, and clinical support staff, helping patients 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 a multidisciplinary team 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 the area of expertise.
• Provides educational support to patients 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 to minimize readmission rates and help reduce the cost of care.
• Assists in facilitating care coordination for the patient across the care continuum, ensuring the highest level of quality care in each setting.
• Develops care plans that address the patient’s overall health, including health goals aligned with the patient’s choices and values.
• Informs patients regarding access to general preventative care practices and supports patient activation of the care plan.
• Reviews and maintains patient health information, including medical records and other pertinent information that informs providers and care team members about the 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.
• Provides after-hours on-call support for urgent care coordination issues.
• Performs other related duties as directed or required.

Requirements

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

Qualifications (Preferred)

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

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. Benefits include:

• Tuition reimbursement and loan forgiveness.
• 401(k) matching.
• Lifecycle benefits.