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Community Nurse Care Coordinator job in Chicago at The University of Chicago Medicine

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Community Nurse Care Coordinator at The University of Chicago Medicine

Community Nurse Care Coordinator

The University of Chicago Medicine Chicago, IL Full-Time

Job Description

Join a world-class academic healthcare system, UChicago Medicine Care Network, as a Community Nurse Care Coordinator.

The South Side Healthy Community Organization, Inc. (SSHCO) is a coalition created to improve access to care across Chicagos South Side. There are 13 Chicago hospitals, health systems and federally qualified health centers participating in SSHCO is a collaboration model, which is dedicated to expanding primary, specialty, and preventative care to increase support in our community.  The development of a technology platform plans to connect South Side providers to better coordinate and provide care for our patients across the continuum.

As an integral member of the SSHCO, the Community Nurse Care Coordinator will be assigned to work with the SSHCO team at SSHCOs site as part of a collaborative SSHCO multi-disciplinary care team to ensure patient needs for the South Sides underserved patient population are met and care delivery is coordinated across the continuum.  The Nurse Care Coordinator acts as a patient advocate, responding with empathy and respect to resolve and assist with patient/family concerns. In this role, you will utilize critical thinking skills to perform timely coordination to meet individuals unique healthcare needs to promote positive outcomes. You will seek the expertise of primary care physicians, medical directors, specialists, social workers, and other disciples involved in the collaboration model. The Nurse Care Coordinator with also assist patients and family members to work with Chicagoland community and state agencies to coordinate care for patients with chronic diseases. Positive and professional efforts will be targeted to promote patient/provider satisfaction and to resolve patient care issues with the development of patient-centered care plans. Care plans are developed based on mutual goals for the patient, family, and the providers emergency plan, medical summary, and ongoing action plan as appropriate. Close monitoring of patient adherence and goal progress takes place within the plan of care, and changes are facilitated as needed. In addition, the Care Coordinator provides and assesses quality, levels of care and identifying and reporting potential risk management issues. The incumbent performs duties and tasks in accordance with performance standards established for the job. They are also responsible for participation in, and completion of, all patient safety initiatives appropriate to the position. The Care Coordinator conducts all job responsibilities in coalescence with the mission and values of SSHCO.

Essential Job Functions:

  • Works in conjunction with SSHCOs developing high-performing team that incorporates leadership principles to assess, plan and initiate patient care.
  • Maintains the ability to work with a designated caseload and deal with rapidly changing priorities.
  • Demonstrates the ability to collaborate with multidisciplinary team for successful preventative care visits to reduce the severity of the chronic disease and avoidable acute illness.
  • Creates and manages a patient centered plan of care for acute and chronic conditions to promote health behaviors in all populations and ensure navigation assistance within the healthcare system.
  • Identifies, plans, and facilitates strategies to provide appropriate clinical health coaching to support patients with self-management of their chronic disease and lifestyle changes to mitigate health risk.
  • Identifies patients who require community support and facilitates a comprehensive approach to the social determinants of health to help patients overcome obstacles that keep them from receiving the care they need.
  • Ensures that all critical elements of the care plan and transition of care plan have been communicated to physician, multi-disciplinary team, patient and family including expediting teaching needs.
  • Completes tasks related to transition of care documents, quality care gaps, and various other quality and performance measure processes. Ensures adherence to Quality Standards and Participation in Quality Monitoring and Improvement.
  • Assumes responsibility for own professional growth and attendance to in-service educational opportunities.
  • Performs other duties as assigned and pays close attention to detail and accuracy of documentation of records along with proficient use of multiple databases and IT resources.
  • Maintains ongoing member case load for regular outreach and management.
  • Demonstrates professional and effective written and verbal communication skills.

Required Qualifications:

  • A Bachelors degree in Nursing from an accredited academic body.
  • An active Registered Nurse license through the State of Illinois.
  • 5 or more years experience working in a clinical setting as a Registered Nurse.
  • Experience working in case management, care coordination, or home health.

Preferred Qualifications:

  • A certification in Case Management preferred and required within 3 years of hire.

Position Details:

  • Job Type/FTE: Full Time (1.0 FTE)
  • Shift: 8-hour shift 8:00am to 4:30pm- Monday-Friday.

Recommended Skills

  • Attention To Detail
  • Care Coordination
  • Case Management
  • Certified Nurse Practitioner
  • Clinical Works
  • Communication
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