About Job
- Works in conjunction with a developing high-performing team that incorporates leadership principles to assess, plan and initiate patient care.
- Maintains the ability to work in a high volume caseload, based on department expectations, and deal with rapid changing priorities.
- Demonstrates the ability to collaborate with multidisciplinary teams for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness.
- Creates and manages a patient centered plan of care for acute and chronic conditions to promote health behaviors in all populations and ensure navigation assistance within the healthcare system.
- Identifies, plans, and facilitate strategies to provide appropriate clinical health coaching to support patients with self-management of their chronic disease and lifestyle changes to mitigate health risk.
- Identifies patients who require community support and facilitate a comprehensive approach to the social determinants of health to help patients overcome obstacles that keep them from receiving the care they need.
- Ensures that all critical elements of the care plan and transition of care plan have been communicated to physicians, multi-disciplinary teams, patients and family including expediting teaching needs.
- Completes tasks related to transition of care documents, quality care gaps, and various other quality and performance measure processes. Ensures adherence to Quality Standards and Participation in Quality Monitoring and Improvement.
- Assumes responsibility for own professional growth and attendance to in-service educational opportunities.
- Performs other duties as assigned and pays close attention to detail and accuracy of documentation of records along with proficient use of multiple databases and IT resources.
- Maintains ongoing member case load for regular outreach and management.
- Must have a bachelor’s degree in nursing from an accredited academic body.
- Must be a licensed Registered Nurse with a valid, unrestricted State license.
- Must have a minimum of three years' experience working in a clinical setting as a Registered Nurse.
- Must have experience working in case management or care coordination.
- Certification in Case Management preferred. (i.e. CCM, CCCTM, etc.).
- Job Type/FTE: Full time
- Shift: 8:00-4:30PM
- Unit/Department: Center for Transformative Care
- CBA Code: Non-Union
- Work Location: One or more primary care clinics located in Western Suburbs. Why Join Us:
Professional Field



Patient Focus
Diagnoses
Avoidant Personality Disorder
Gender Dysphoria
Issues
COVID
Medication Management
Minority Health
Therapeutic Approach
Methodologies
ECT
Modalities
Families
Individuals
Practice Specifics
Populations
Victims of Crime/Abuse (VOC/VOA)
Racial Justice Allied
School
Settings
Faith-based organizations
Research Facilities/Labs/Clinical Trials
Schools
Home Health/In-home
Military
Forensic
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