RN Care Coordinator / Ambulatory Virtual Nursing

Emory•Atlanta, GA

1d•Remote

About The Position

Emory Healthcare is hiring an RN Care Coordinator for its Telehealth Nursing department. The role provides proactive virtual patient outreach and care coordination for a panel of patients, with the goal of achieving optimal health and wellness outcomes while reducing preventable emergency department visits, hospitalizations, and readmissions. The RN serves as a clinical liaison, facilitator, advocate, and collaborator in a multidisciplinary care team, supporting complex disease management for identified high-risk and post-discharge patients and advancing population health management activities. The position uses assessment and risk-assessment tools to identify patient needs and barriers, establish patient-centered goals, create and reassess care plans, coordinate access to services, and support patient and family communication. The RN provides education and self-management support, evaluates care coordination outcomes, updates plans, helps close care gaps, documents evaluation results, and contributes to quality improvement and care transformation. Post-acute responsibilities may include ensuring discharge records and orders are complete, coordinating transitions among inpatient, skilled nursing, rehabilitation, home health, and home settings, and monitoring therapy progress and discharge readiness. The schedule is 8:30 a.m.–5:00 p.m. Training is onsite for 6–8 weeks. A multistate nursing license is required for this telehealth role. Emory Healthcare describes its environment as supportive and offers professional mentorship, development, and leadership programs.

Requirements

Graduate of an accredited nursing school.
Bachelor of Science in Nursing (BSN) degree required.
Three years of healthcare experience required.
Valid, active, unencumbered nursing license or temporary permit approved by the Georgia Licensing Board.
BLS Healthcare Provider certification.
For virtual care activities that may include multistate practice, an active compact/multistate license (eNLC) is required within 60 days of hire. Employees in the role before 11/09/2025 have until their next renewal date to achieve compact status.
A multistate nursing license is required for this telehealth role.

Nice To Haves

Care Management experience.

Responsibilities

Use assessment skills and risk-assessment tools to collect health information and identify barriers requiring a team-based approach.
Use a holistic, patient-centered, evidence-based approach to set patient-centered goals and develop outcomes that improve health status and patient satisfaction.
Reassess patients to determine current health status and progress toward healthcare goals and care-plan completion.
Conduct targeted outreach to patient panels to support timely, efficient care delivery across the continuum.
Improve communication and collaboration among patients, families, healthcare teams, and community-based organizations.
Serve as a primary point of contact for identified high-risk and post-discharge patients and facilitate their access to services.
Partner with care coordination teams across Emory Healthcare and with community organizations.
Enhance health literacy using teach-back and other methods of validating learning.
Provide self-management support using information technologies to communicate health promotion and disease prevention information.
Systematically evaluate outcomes in care coordination plans of care and update patient care plans as appropriate.
Help ensure care gaps are closed around specialty and chronic diseases.
Assimilate and document the results of evaluative processes.
Monitor performance and quality-improvement measures and care transformation in the assigned clinical area.
Integrate data analysis and performance-improvement initiatives into practice to improve coordination among multiple entities.
Apply critical thinking and clinical judgment when implementing population health interventions or planning care for patients, groups, and families.
Participate in professional organizations and continuing education activities related to care coordination and population health.
For post-acute areas, ensure records and orders from the discharging acute facility are complete.
For post-acute areas, facilitate transitions across inpatient, skilled nursing facility, inpatient rehabilitation facility, home health, and home settings.
For post-acute areas, establish and maintain a high-quality relationship with the Medicare Nurse/Team.
For post-acute areas, monitor therapy progress and discharge readiness.
For post-acute areas, maintain relationships with network leaders to escalate post-care outcomes.
Perform other area-specific duties.