Care Coordinator 3 RN

AUNT MARTHAS HEALTH AND WELLNESS•Park Forest, IL

3d•Onsite

About The Position

The Care Coordinator 3 RN makes a direct impact on patients with complex healthcare needs. This role helps high- and medium-risk patients navigate transitions of care, manage chronic health needs, avoid unnecessary hospitalizations, and become more engaged in their own health and wellness. This is an excellent opportunity for a nurse who enjoys patient education, case management, interdisciplinary collaboration, and building meaningful relationships with patients and families. The Care Coordinator 3 RN monitors and coordinates the healthcare needs of patients to ensure appropriate and timely delivery of services. This position provides comprehensive assessments, develops and monitors individualized care plans, coordinates transitions following hospitalization or skilled nursing care, performs medication reconciliation, provides disease-management education, and connects patients and families with healthcare and community resources. The Care Coordinator 3 RN works closely with primary care providers, nurses, social workers, hospitals, specialists, clinic staff, patients, and families to improve health outcomes and reduce unnecessary emergency department visits and hospital readmissions.

Requirements

Bachelor of Science Degree in Nursing (BSN) preferred.
OR Associate Degree with at least two years of experience working in the healthcare field preferred.
LPN/LVN license with three years of healthcare experience.
Strong clinical assessment, patient education, and care-coordination skills.
Experience working with Microsoft Office programs and performing accurate data entry.
Comfortable learning and working within Electronic Health Record systems.
Current driver's license.
Current automobile insurance.
Ability to work late evenings, weekends, or scheduled holidays as needed by the program.
Ability to provide face-to-face patient services as required.
Ability to provide departmental coverage as needed.
Ability to occasionally lift and/or move up to 10 pounds.

Nice To Haves

Care coordination or case-management experience.
Experience working with high-risk or medically complex patients.
Hospital discharge and transition-of-care experience.
Medication reconciliation experience.
Chronic disease management and patient education.
Experience working within multidisciplinary healthcare teams.
Experience connecting patients with healthcare and community resources.
Bilingual English/Spanish skills are a plus.

Responsibilities

Complete comprehensive assessments for patients enrolled in care management, including appropriate physical and psychosocial assessments.
Identify and prioritize patients based on risk level, healthcare needs, and required follow-up.
Develop individualized care-management plans for high-risk patients.
Establish measurable SMART goals with patients, families, and the healthcare team.
Review and update care plans for high-risk patients within required program timeframes.
Periodically reassess patients' healthcare and social-service needs.
Provide ongoing follow-up to support patients in reaching established health goals.
Identify patients at risk for hospitalization or unnecessary emergency department utilization.
Coordinate care and connect patients with appropriate resources to help prevent avoidable hospital or emergency department visits.
Assist patients and healthcare teams with transition planning following hospitalization or skilled nursing facility care.
Help ensure discharge information is available to the patient's primary care provider within required timeframes.
Review discharge information with patients and families.
Coordinate timely primary care follow-up appointments following discharge.
Conduct follow-up calls with patients recently discharged from acute hospitalization or considered at high risk for readmission.
Perform medication reconciliation during care transitions.
Provide disease-management and health education.
Educate patients regarding appropriate emergency department utilization and preventive healthcare.
Promote patient self-management and help patients and families achieve greater independence in managing their healthcare.
Engage patients and families in developing and maintaining their individualized plan of care.
Conduct health screenings as appropriate.
Provide referrals for medical, social, and community-based services and follow up on referral outcomes.
Collaborate with physicians, nurses, social workers, care-team leaders, specialists, hospitals, and other healthcare professionals.
Coordinate with internal Aunt Martha’s programs and external community organizations to address patients' medical and social needs.
Identify and effectively utilize community resources for patients and families.
Participate as part of a multidisciplinary healthcare team.
Serve as a liaison between hospitals, skilled nursing facilities, primary care providers, patients, and families.
Participate in regular team meetings, supervision, and peer-review activities.
Assist with orientation, precepting, and mentoring of team members.
Accurately document patient assessments, care plans, interventions, and outcomes within the Athena Electronic Health Record (EHR).
Maintain timely and accurate documentation in the electronic medical record.
Manage databases and outcomes data as required.
Complete reports and projects accurately and within established deadlines.
Maintain patient confidentiality and follow HIPAA and organizational requirements.
Participate in performance-improvement initiatives and organizational compliance activities.