RN Care Coordinator / Ambulatory Care Coordination at Emory Healthcare

Tucker, Georgia, United States -

Full Time

Start Date

Immediate

Expiry Date

14 May, 26

Salary

0.0

Posted On

13 Feb, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Patient Assessment, Risk Assessment, Goal Setting, Care Coordination, Clinical Liaison, Facilitator, Advocate, Collaborator, Disease Management, Health Literacy, Self-Management Support, Quality Improvement, Data Analysis, Critical Thinking, Clinical Judgement, Population Health

Industry

Hospitals and Health Care

Description

Overview Be inspired. Be rewarded. Belong. At Emory Healthcare. 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. We provide: 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 Description We are seeking a capable RN Care Coordinator who has acquired broad experience in caring for patients and has developed a sound understanding about the care of a particular patient population. Proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient and readmission visits. Functions as a clinical liaison, facilitator, advocate and collaborator in a multidisciplinary care team across the continuum of care to provide complex disease management interventions to high risk and post discharged patients identified. Facilitates transformational care delivery in clinical settings and advance the mission and goals of population management activities. Primary duties and responsibilities: Patient Assessment and Goal Setting: 1. Utilizing assessment skills and risk assessment tools to collect subjective and objective information pertaining to the health status of the patient and identify barriers that will require a team-based approach. 2. Utilize a team-based, holistic, patient-centered, evidence based approach to identify patient-centered goals and develop outcomes to improve the health status of Emory Healthcare patients and improve patient satisfaction. 3. Performs patient re-assessments to determine current health status and progress toward healthcare goals and care plan completion. Care Coordination and Outreach: 1. Conducts targeted outreach to identified patient panels to ensure timely and efficient care delivery across the continuum of care. 2. Improve communication and collaboration between patient and families, healthcare teams and community-based organizations. 3. Serve as a primary point of contact for identified high risk and post-discharged patients and facilitate access to services. 4. Partners with other care coordination teams across the Emory Healthcare system and community organizations. Education and Self-Management Support: 1. Enhance health literacy by using teach back and other various forms of learning validation. 2. Provide self-management support with the use of information technologies to communicate health promotion and disease prevention information. Evaluation and Quality Improvement: 1. Conduct systematic, ongoing, and criterion-based evaluation of outcomes in care coordination plans of care. 2. Updates patient care plan, as appropriate. 3. Ensure care gaps are closed around specialty/chronic diseases. 4. Assimilate and document the results of the evaluative processes. 5. Monitor key measures of performance, quality improvement and care transformation in the assigned clinical area. 6. Integrate data analysis and performance improvement initiatives into practice with the aim of improving care coordination among multiple entities. 7. Apply critical-thinking skills and the use of clinical judgement when implementing population health interventions or planning effective care for groups or individual patients and their families. Professional Development and Other Duties: 1. Participates in professional organizations and attend continuing education activities to maintain knowledge of current trends and practices as it relates to care coordination and population health. In addition, other area specific job duties Minimum Qualifications required: Education - Graduate of an accredited nursing school. Bachelors 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 - 1. BLS Healthcare Provider certification 2. If completing virtual care activities that may include multi-state practice, an active compact/multistate license (eNLC) is required within 60 days of hire. Employees in role prior to 11/09/2025 will have until their next renewal date to achieve compact status Preferred Qualifications: Experience - Care Management experience. JOIN OUR TEAM TODAY! Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties. Additional Details 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. Please contact Emory Healthcare’s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.

Responsibilities

The RN Care Coordinator will conduct proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and reduce preventable emergency department, inpatient, and readmission visits. This role involves functioning as a clinical liaison, facilitator, advocate, and collaborator within multidisciplinary teams to manage complex diseases for high-risk and post-discharged patients.