RN Nurse Care Coordinator; Bilingual - Spanish

Overview

Position Overview The RN Nurse Care Coordinator is a dynamic, highly collaborative, and patient-focused role that leverages clinical expertise to advocate for and manage the care of high-risk patients. This position is central to the SSHCO model of care, focusing on improving patient outcomes by coordinating services and providing personalized support.

• Identifies, tracks, and manages a designated caseload of high-risk patients.
• Conducts initial screenings and comprehensive risk assessments to develop, implement, and provide clinical oversight for individualized patient care plans. This includes setting mutual goals with the patient and family.
• Facilitates a team-based approach to care by collaborating with a multidisciplinary team (including physicians, specialists, LPNs, social workers, and other staff), as well as with patients, families, and community/state agencies.
• Acts as a patient advocate, proactively addressing patient and provider concerns and empowering patients with chronic diseases through individualized clinical health coaching to promote self-management.
• Ensures clear and comprehensive communication of care plans to all members of the care team, including physicians, the patient, and their family. Manages transition of care documents and ensures all treating clinicians have up-to-date access to patient information.
• Closely monitors patient adherence to care plans, tracks progress towards goals, addresses quality care gaps, triggers medical reviews as necessary, and contributes to broader quality improvement initiatives.
• Acts as a leader within the interdisciplinary team, delegating appropriate tasks to LPN Nurse Care Coordinators and Community Health Workers to maximize team efficiency.
• Manages special member populations and participates in various Care Coordination initiatives, pilots, and programs as needed.
• Adapts communication and care approaches to address individual patient needs, considering factors such as health literacy, cultural background, and physical limitations.
• Actively participates in and champions all patient safety initiatives relevant to the role.

Please note this description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of this position. Duties, responsibilities, and activities may change at any time with or without notice.

• Must be willing and able to travel throughout the Chicagoland area, including to home visits, community events, clinics, and hospital partner sites. The typical schedule is weekdays from 8:00 AM to 4:30 PM, with flexibility for occasional weekend or evening work.
• NEW GRAD ACCEPTED, but 1+ years of experience in a clinical, outpatient, care coordination, or home health setting is preferred. A current RN license in the State of Illinois and CPR certification are required.
• Up-to-date vaccinations, including influenza and COVID-19, are required prior to the start date.
• A thorough knowledge of care coordination principles is necessary. Excellent communication, interpersonal, time management, and organizational skills are essential. Computer skills including strong proficiency with EMR systems (e.g., Athena, Epic, Cerner) and Microsoft Office Suite (Excel, Teams, Outlook) are needed.
• Must be detail-oriented, accurate, open-minded, and adaptable to change. Must be able to thrive in a collaborative team environment while also working independently with minimal supervision. Familiarity with Chicago's West and/or South Side communities is preferred.
• Commitment to living SSHCO's mission, vision, and values in daily work and behaviors.