Ambulatory Nurse Care Coordinator

Ambulatory Nurse Care Coordinator – Full Time – Sign‑On Bonus Offered

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient‑first approach sets us apart as a leader in the healthcare industry. As an integral part of our team, you’ll have the opportunity to join our quest for better health care across the entire Northwestern Medicine system. We pride ourselves on providing competitive benefits, including tuition reimbursement, loan forgiveness, 401(k) matching, and lifecycle benefits to care for our employees.

The Ambulatory Nurse Care Coordinator reflects the mission, vision, and values of NM. The role adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, all regulatory requirements, and accreditation standards. The coordinator provides patient care support and ensures high quality of care through education and robust care‑management coordination services. They function as a liaison between the patient, physician, and clinical support staff, helping patients understand their medical conditions and health responsibilities.

• Serves as a patient advocate in an ambulatory setting and assists in navigating across various care settings.
• Addresses the care coordination needs for high‑ and moderate‑risk patients as well as assistance with low‑risk or new patients.
• Reviews patient records, registries, reports, or other encounter or claims data to identify patients who may require care coordination.
• Assesses, documents, and addresses clinical, psychosocial, or financial barriers to effective patient care.
• Consults with multidisciplinary team as appropriate to develop, implement, and evaluate care for patients and families specific to the area of expertise.
• Provides effective triage care using in‑depth clinical knowledge and skills in the area of expertise.
• Provides educational support to patients and family members around medical processes, procedures, treatments, medications, and management of health and wellness.
• Ensures timely continuity of care by proactively outreaching to patients post‑discharge, managing referrals, facilitating transitions of care, and coordinating community resources. Collaborates across the continuum with patients’ care team members.
• Manages high‑risk patient cases to minimize readmission rates and help reduce the cost of care. Assists in facilitating care coordination across the care continuum, ensuring that the patient receives the highest level of quality care in each setting.
• Develops a care plan that addresses the patient’s overall health, including health goals with a plan aligned with the patient’s choices and values. Informs patients regarding access to general preventative care practices and supports patient activation of the care plan.
• Reviews and maintains patient health information, including medical records and other pertinent information that informs provider and care team members about the patient’s health and progress of care outcomes.
• Monitors the quality of care, as well as patient and physician satisfaction, through follow‑up discussions and assessments. Participates in continuous quality, performance, and improvement initiatives to enhance care coordination.
• Provides after‑regular‑business‑hours on‑call support for urgent care coordination issues.
• Performs other related duties as directed or required.

• Current license as a Registered Nurse – State of Illinois Professional Nurse.
• Bachelor of Nursing Degree (BSN) with three to five years of relevant clinical experience, or BSN required within two years of hire.
• 3 years of experience (5 years preferred) working with chronic conditions, evidence‑based medicine, care coordination, care management, and psychosocial and behavioral factors affecting health outcomes.
• Willingness to travel (some travel may be required).

• 3 years of experience in Care Management or Care Coordination.
• Case Management certification preferred or willingness to complete upon meeting eligibility criteria.
• Experience with…