Care Coordinator 3 RN - Chicago Heights, IL

This job was posted by https://illinoisjoblink.illinois.gov : For more information, please see: https://illinoisjoblink.illinois.gov/jobs/13803075 # Care Coordinator 3 RN {#care-coordinator-3-rn pasted="true"} 2 openings- Chicago Heights IL\ Department: Care Coordination\ Schedule: Full-Time\ Compensation: $70,000 annually\ Bilingual English/Spanish preferred 2 openings- ## About Aunt Marthas Health & Wellness At Aunt Marthas Health & Wellness, we are committed to improving the health and well-being of the communities we serve through compassionate, coordinated, and patient-centered care. Our Care Coordination team works closely with primary care providers, hospitals, specialists, community resources, and patients to help ensure individuals receive the right care and support at the right time. As a Care Coordinator 3 RN, you will have the opportunity to make a direct impact on patients with complex healthcare needs. Youll help high- and medium-risk patients navigate transitions of care, manage chronic health needs, avoid unnecessary hospitalizations, and become more engaged in their own health and wellness. This is an excellent opportunity for a nurse who enjoys patient education, case management, interdisciplinary collaboration, and building meaningful relationships with patients and families. ## Position Overview Under the direct supervision of the Care Coordination Nurse Supervisor, the Care Coordinator 3 RN monitors and coordinates the healthcare needs of patients to ensure appropriate and timely delivery of services. This position provides comprehensive assessments, develops and monitors individualized care plans, coordinates transitions following hospitalization or skilled nursing care, performs medication reconciliation, provides disease-management education, and connects patients and families with healthcare and community resources. The Care Coordinator 3 RN works closely with primary care providers, nurses, social workers, hospitals, specialists, clinic staff, patients, and families to improve health outcomes and reduce unnecessary emergency department visits and hospital readmissions. ## Key Responsibilities ### Clinical Care Coordination - Complete comprehensive assessments for patients enrolled in care management, including appropriate physical and psychosocial assessments. - Identify and prioritize patients based on risk level, healthcare needs, and required follow-up. - Develop individualized care-management plans for high-risk patients. - Establish measurable SMART goals with patients, families, and the healthcare team. - Review and update care plans for high-risk patients within required program timeframes. - Periodically reassess patients' healthcare and social-service needs. - Provide ongoing follow-up to support patients in reaching established health goals. ### Transitions of Care - Identify patients at risk for hospitalization or unnecessary emergency department utilization. - Coordinate care and connect patients with appropriate resources to help prevent avoidable hospital or emergency department visits. - Assist patients and healthcare teams with transition planning following hospitalization or skilled nursing facility care. - Help ensure discharge information is available to the patient's primary care provider within required timeframes. - Review discharge information with patients and families. - Coordinate timely primary care follow-up appointments following discharge. - Conduct follow-up calls with patients recently discharged from acute hospitalization or considered at high risk for readmission. - Perform medication reconciliation during care transitions. ### Patient Education & Support - Provide disease-management and health education. - Educate patients regarding approp iate emergency department utilization and preventive healthcare. - Promote patient self-management and help patients and families achieve greater independence in managing their healthcare. - Engage patients and families in developing and maintaining their individualized plan of care. - Conduct health screenings as appropriate. - Provide referrals for medical, social, and community-based services and follow up on referral outcomes. ### Collaboration & Community Resources Collaborate with physicians, nurses, social workers, care-team leaders, specialists, hospitals, and other healthcare professionals. Coordinate with internal Aunt Marthas programs and external community organizations to address patients' medical and social needs. Identify and effectively utilize community resources for patients and families. Participate as part of a multidisciplinary healthcare team. Serve as a liaison between hospitals, skilled nursing facilities, primary care providers, patients, and families. Participate in r