RN Care Navigator: Patient Care & Transitions

Position Summary The RN Care Coordinator is a Registered Nurse who provides care coordination, medical and disease education, and outreach services to assist patients in navigating health care transitions and supports patient empowerment through health education, advocacy, and coaching. The RN Care Coordinator ensures the continuity and quality of care for patients with multiple complex medical conditions, as well as chronic diseases, with goals of self-management. The person in this position provides care coordination with a Triple Aim approach in mind: Improve patient experience, improve population health, and lower the cost of health care. Core Job Responsibilities Serve as team lead for intake process, development and maintenance of care plan and promoting health programs and services. Utilize information systems and decision support, manages a patient panel to proactively contact, educate, and track patients by disease, risk, and self-management status, as well as family and community need. Lead Patient-Centered Care Planning based upon the nursing process to include assessment, plan, implementation/intervention, and evaluation, as well as a method for monitoring and intervening. Conduct home/community visits (face-to-face) according to policy and workflows. Provide resources to support patient/families in self-management to meet health care treatment goals, assess readiness to learn and validate learning outcomes. Collaborate with interdisciplinary teams and health care team members both internal and external to the organization to improve patient care through effective utilization and monitoring of health care resources. Assist patients and providers from across the care continuum in the transition from outpatient- to inpatient setting, and ensure post-emergency department, hospitalization, and/or specialist follow up. Appropriately and in a timely manner, document interactions, findings, and continuum of care-related activities in the electronic medical record to assure optimal patient care reporting on quality improvement efforts. Work collaboratively with the quality department to improve patient outcomes through the review of patient care gaps, educating patients on the importance of prevention care and ongoing needed assessments, remain aware of quality initiatives and ACCESS quality priorities. Perform other responsibilities as assigned to support health equity initiatives. Requirements/Preferences Associate’s degree required. Bachelor’s degree preferred. Registered Nurse (RN); current unrestricted licensure in Illinois, required. A minimum of one (1) year of health care experience preferred Case management and/or care coordination experience preferred. Bilingual Spanish a plus Previous experience using an electronic medical record preferred. Intermediate proficiency in Microsoft Office products (Word, Excel, PowerPoint). #J-18808-Ljbffr Access Community Health Network