RN Care Coordinator / Outpatient Cardiology

About the role

We are seeking a capable RN Care Coordinator who has acquired broad experience in caring for patients and has developed a sound understanding about the care of a particular patient population. Proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient and readmission visits.

Responsibilities

• Patient Assessment and Goal Setting:
  • Utilizing assessment skills and risk assessment tools to collect subjective and objective information pertaining to the health status of the patient and identify barriers that will require a team-based approach.
  • Utilize a team-based, holistic, patient-centered, evidence based approach to identify patient-centered goals and develop outcomes to improve the health status of Emory Healthcare patients and improve patient satisfaction.
  • Performs patient re-assessments to determine current health status and progress toward healthcare goals and care plan completion.
• Care Coordination and Outreach:
  • Conducts targeted outreach to identified patient panels to ensure timely and efficient care delivery across the continuum of care.
  • Improve communication and collaboration between patient and families, healthcare teams and community-based organizations.
  • Serve as a primary point of contact for identified high risk and post-discharged patients and facilitate access to services.
  • Partners with other care coordination teams across the Emory Healthcare system and community organizations.
• Education and Self-Management Support:
  • Enhance health literacy by using teach back and other various forms of learning validation.
  • Provide self-management support with the use of information technologies to communicate health promotion and disease prevention information.
• Evaluation and Quality Improvement:
  • Conduct systematic, ongoing, and criterion-based evaluation of outcomes in care coordination plans of care.
  • Updates patient care plan, as appropriate.
  • Ensure care gaps are closed around specialty/chronic diseases.
  • Assimilate and document the results of the evaluative processes.
  • Monitor key measures of performance, quality improvement and care transformation in the assigned clinical area.
  • Integrate data analysis and performance improvement initiatives into practice with the aim of improving care coordination among multiple entities.
  • Apply critical-thinking skills and the use of clinical judgement when implementing population health interventions or planning effective care for groups or individual patients and their families.
• Professional Development and Other Duties:
  • Participates in professional organizations and attend continuing education activities to maintain knowledge of current trends and practices as it relates to care coordination and population health.

Requirements

• Education - Graduate of an accredited nursing school. Bachelors degree in Nursing (BSN) required.
• Experience - Three (3) years of healthcare experience required.
• Licensure - Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
• Certification - 1. BLS Healthcare Provider certification 2. If completing virtual care activities that may include multi-state practice, an active compact/multistate license (eNLC) is required within 60 days of hire.

Qualifications

• Experience - Care Management experience.

Skills

Proactive patient outreach and care coordination, patient-centered care, evidence-based practice, communication and collaboration, self-management support, health literacy, data analysis, critical thinking, clinical judgement.

Benefits

Comprehensive health benefits that start day 1, Student Loan Repayment Assistance & Reimbursement Programs, Family-focused benefits, Wellness incentives, Ongoing mentorship, development, and leadership programs, and more.

Pay

N/A

Schedule

N/A