Care Coordinator

• Conduct proactive patient outreach and care coordination for assigned patient panels
• Assess patient health status, risks, barriers, goals, and progress toward care-plan completion
• Develop patient-centered outcomes and care plans using a holistic, evidence-based, team-based approach
• Conduct targeted outreach to high-risk and post-discharged patients
• Serve as a primary contact and facilitate access to services
• Collaborate with patients, families, healthcare teams, community organizations, and Emory care coordination teams
• Enhance health literacy using teach-back and other learning-validation methods
• Provide self-management, health-promotion, and disease-prevention support using information technologies
• Evaluate care-coordination outcomes and update patient care plans
• Close specialty and chronic-disease care gaps
• Document evaluative results and monitor performance and quality-improvement measures
• Integrate data analysis and performance-improvement initiatives into practice
• Apply critical thinking and clinical judgment to population-health interventions and individual patient care
• Participate in professional organizations and continuing-education activities
• Ensure completeness of records and orders from discharging acute facilities in post-acute areas
• Facilitate transitions across inpatient, SNF, IRF, HHA, and home settings
• Monitor therapy progress and discharge readiness
• Maintain relationships with Medicare nurses/teams and network leaders to escalate post-care outcomes

Explore RN Care Coordinator – Ambulatory Virtual Nursing at Emory Healthcare. Review requirements and application details.