Ambulatory Nurse Care Coordinator, Full-time, Days (Hybrid)

THIS POSITION WILL REQUIRE TRAVEL TO OUR CENTRAL REGION CLINICSThe Ambulatory Nurse Care Coordinator reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.The Ambulatory Nurse Care Coordinator is responsible for providing patient care support services and ensuring high quality of care through education and robust care management coordination services. The Ambulatory Nurse Care Coordinator functions as a liaison between the patient, physician, and clinical support staff and helps the patient understand their medical conditions and health responsibilities.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 health 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 area of expertise.Provides educational support to patient 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 in order to minimize readmission rates and help reduce the cost of care. Assists in facilitating care coordination for the patient across the care continuum, ensuring that the patient is receiving the highest level of quality care in each setting.  Develops care plan that addresses patient’s overall health, including health goals with a plan that is in line with patient’s choices and values. Informs patients regarding access to general preventative care practices. Support patient activation of care plan.   Reviews and maintains patient health information including medical records and other pertinent information that informs provider and care team members about patient’s health and progress of care outcomes.Monitors 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 ensure the improvement of care coordination.Provide after regular business hours on-call support for urgent care coordination issues.    Performs other related duties as directed or required.