[Hiring] RN Care Coordinator / Ambulatory Virtual Nursing @Emory Healthcare

Role Description

Be inspired. Be rewarded. Belong. At Emory Healthcare, we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be.

• Proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness.
• Decrease preventable ED, inpatient and readmission visits.
• Functions as a clinical liaison, facilitator, advocate and collaborator in a multidisciplinary care team.
• Facilitates transformational care delivery in clinical settings.

Primary duties and responsibilities:

• Patient Assessment and Goal Setting:
  • Utilizing assessment skills and risk assessment tools to collect subjective and objective information.
  • Identify barriers that will require a team-based approach.
  • Utilize a team-based, holistic, patient-centered, evidence-based approach to identify patient-centered goals.
  • Perform patient re-assessments to determine current health status and progress toward healthcare goals.
• Care Coordination and Outreach:
  • Conduct targeted outreach to identified patient panels.
  • Improve communication and collaboration between patients, families, healthcare teams, and community-based organizations.
  • Serve as a primary point of contact for identified high-risk and post-discharged patients.
  • Partner with other care coordination teams across the Emory Healthcare system.
• Education and Self-Management Support:
  • Enhance health literacy using teach back and other forms of learning validation.
  • Provide self-management support using information technologies.
• Evaluation and Quality Improvement:
  • Conduct systematic, ongoing, and criterion-based evaluation of outcomes in care coordination plans.
  • Update patient care plan as appropriate.
  • Ensure care gaps are closed around specialty/chronic diseases.
  • Document the results of the evaluative processes.
  • Monitor key measures of performance, quality improvement, and care transformation.
  • Integrate data analysis and performance improvement initiatives into practice.
  • Apply critical-thinking skills and clinical judgment when implementing population health interventions.
• Professional Development and Other Duties:
  • Participate in professional organizations and attend continuing education activities.
• Additional Responsibilities for working in Post-Acute Areas:
  • Ensure completeness of record/orders from discharging acute facility.
  • Facilitate seamless transitions across inpatient, SNF, IRF, HHA, and home.
  • Establish and maintain a high-quality relationship with the Medicare Nurse/Team.
  • Monitor therapy progress and discharge readiness.

Qualifications

• Education: Graduate of an accredited nursing school. Bachelor's degree in Nursing (BSN) required.
• Experience: Three (3) years of healthcare experience required.
• Licensure: Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
• Certification:
  • BLS Healthcare Provider certification.
  • If completing virtual care activities, an active compact/multistate license (eNLC) is required within 60 days of hire.

Requirements

• Care Management experience preferred.

Benefits

• Comprehensive health benefits that start day 1.
• Student Loan Repayment Assistance & Reimbursement Programs.
• Family-focused benefits.
• Wellness incentives.
• Ongoing mentorship, development, and leadership programs.
• And more.

Company Description

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request.