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Near North Health is Hiring a NM Transition of Care Coordinator Near Chicago, IL

Responsibilities:

Position Summary:  The Transitions of Care Coordinator will manage and oversee the continuum of care for patients interfacing with the Northwestern Medicine Emergency Department and Transitions Clinic. This pivotal role ensures a seamless transition for patients who either lack a medical home or have designated Near North Health as their primary provider. The coordinator will be responsible for creating effective transition plans, collaborating with members of the healthcare team and patients and their families to ensure that post-emergency room care is accessible, coordinated, and continuous.  The coordinator integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.
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Essential Duties and Responsibilities:  

1.    Coordinate and implement transition plans for patients from the NM Emergency Room and Transitions Clinic to appropriate follow-up care within the Near North Health system.
2.     Act as a patient advocate, ensuring that each individual receives comprehensive and holistic care that addresses both medical and social determinants of health.
3.    Facilitate communication between hospital staff, primary care providers, specialists, and ancillary services to ensure a cohesive care experience for the patient.
4.    Monitor and track patient follow-ups and outcomes, intervening as necessary to prevent readmissions and promote optimal health.
5.    Educate patients and families about the importance of follow-up care, medication adherence, and available resources within Near North Health and the community.
6.    Work collaboratively with care teams to assess patient needs, including scheduling initial appointments, and connecting patients with resources for transportation, medication assistance, and other social determinant of health support services.
7.    Maintain detailed records of patient interactions, interventions, and transitions using the appropriate health information systems.
8.    Develop relationships with Transitions Clinic staff and other community healthcare entities to promote the Transitions of Care program and ensure its effectiveness.
9.    Participate in team meetings and contribute to quality improvement initiatives aimed at enhancing the transition of care processes.

10.    Collaborate with the clinical leadership in strategic planning for the recruitment, development, retention, and performance evaluation of clinical staff.

Non-Essential Duties and Responsibilities:

Education:      Bachelor’s degree or higher
 
Required Licensure and/or Certification: Nursing licensure if a Nurse

Minimum Experience: Care coordination and continuous quality improvement 
experience preferred

Experience:

•    Minimum of 3 years of experience in care coordination, case management, or a related field, preferably within a healthcare setting.
•    Strong understanding of the healthcare delivery system and the continuum of care model.
•    Excellent organizational skills and the ability to handle multiple priorities effectively.
•    Proficient in health information technology systems, including electronic health records and care management platforms.
•    Exceptional interpersonal and communication skills, with a focus on patient-centered care.
•    Knowledge of community resources and the ability to build community partnerships.
•    Ability to work independently as well as part of a multidisciplinary team.
•    Commitment to the mission and values of Near North Health, with a passion for serving underserved populations.

Additional Requirements:
•    Flexibility to work non-traditional hours including Saturdays and evenings as needed.
•    Availability to work across different site locations within the health system may be required.
 

Job Summary