RN Care Coordinator / Ambulatory Virtual Nursing

Emory Healthcare•Tucker, GA

1d•$47 - $55

About The Position

The RN Care Coordinator provides proactive patient outreach and care coordination for a panel of patients to support optimal outcomes and wellness while reducing preventable emergency department, inpatient, and readmission visits. The role serves as a clinical liaison, facilitator, advocate, and collaborator within a multidisciplinary care team, delivering complex disease management interventions to identified high-risk and post-discharged patients across the continuum of care. The position also supports transformational care delivery and population management activities. In Emory Healthcare’s Telehealth Nursing department, nurses use telecommunications technologies to provide virtual nursing care. Telehealth RNs triage and prioritize patient needs, collaborate with patients on care plans, direct patients to appropriate levels of care, and provide referrals to Emory services and other resources. This role has a scheduled shift of 8:30 a.m. to 5:00 p.m. Training is onsite for 6–8 weeks. A multistate nursing license is required for this telehealth role.

Requirements

Graduate of an accredited nursing school.
Bachelor of Science in Nursing (BSN).
Three years of healthcare experience.
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 subjective and objective health information and identify barriers requiring a team-based approach.
Use a holistic, patient-centered, evidence-based approach to identify patient 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 and efficient care 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-discharged patients and facilitate access to services.
Partner with care coordination teams across Emory Healthcare and community organizations.
Enhance health literacy using teach-back and other methods to validate learning.
Provide self-management support using information technologies to communicate health promotion and disease prevention information.
Systematically evaluate outcomes in care coordination plans and update patient care plans as appropriate.
Ensure care gaps are closed around specialty and chronic diseases.
Assimilate and document evaluation results.
Monitor performance measures, quality improvement, and care transformation in the assigned clinical area.
Integrate data analysis and performance improvement initiatives into practice to improve care coordination among multiple entities.
Apply critical thinking and clinical judgment when implementing population health interventions and planning care for patients, groups, and families.
Participate in professional organizations and continuing education activities to maintain knowledge of current care coordination and population health practices.
For post-acute areas, ensure records and orders from the discharging acute facility are complete and facilitate transitions across inpatient, SNF, IRF, HHA, and home settings.
For post-acute areas, establish and maintain a high-quality relationship with the Medicare Nurse/Team, monitor therapy progress and discharge readiness, and maintain relationships with network leaders to escalate post-care outcomes.