The Supervisor, Community Nurse Care Coordination provides experience and expertise to the SSHCO model of care while acting as a patient advocate. The role utilizes critical thinking skills to perform timely coordination to meet an individual’s unique healthcare needs to promote positive outcomes.

ESSENTIAL JOB FUNCTIONS:

To perform this job successfully, an individual must be able to perform each essential job function satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

• Maintains ongoing member case load for regular outreach and management.
• Creates and manages a patient centered plan of care for acute and chronic conditions to promote healthy behaviors in all populations and ensure navigation assistance within the healthcare system.
• Collaborates with multidisciplinary team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute and/or chronic illness.
• 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.
• Provides and assesses quality, levels of care and identifying and reporting potential risk management issues to the Clinical Manager, Care Coordination.
• Seeks the expertise of primary care physicians, medical directors, specialists, social workers, and other disciplines involved in the collaboration model as needed.
• 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 requested.

SUPERVISORY RESPONSIBILITIES:

• Community Nurse Care Coordinator, LPN

TRAVEL REQUIRED:

• Local travel to healthcare organizations – safety net hospitals, health systems and Federally Qualified Health Centers — on the South Side of Chicago may be required.

QUALIFICATIONS:

• 5 or more years’ experience working in a clinical setting.
• Experience working in care coordination or home health.
• Required knowledge and skill could have been acquired in an inpatient or home health setting but outpatient experience is preferred.

LICENSES/CERTIFICATIONS:

• Requires registration and current RN license in State of Illinois
• CPR certification