Mercy Health Ambulatory Nurse Care Coordinator in Youngstown, Ohio

Ambulatory Nurse Care Coordinator

Job ID: 4651298

Updated: October 5, 2017

Geographic Location: HomeOffice

Location: Youngstown, OH, United States

Department: Care Coordination

Full/Part Time: Full-Time

Shift: Days

Standard Hours: 40

Job Summary

General Purpose:

The RN Ambulatory Care Coordinator’s primary responsibility is to oversee care coordination of Population Health patients for the primary care practice. This includes assessment, developing and monitoring plan of care in collaboration with Primary Care Provider and care team. It also includes identifying the high-acuity patient population and working to ensure care coordination for this patient population. The position may involve some patient triage. The overall goal of the role is to assist patients to progress to successful self-management of chronic health conditions, to assist in removing barriers to adherence of prescribed plan of care, and to reduce unnecessary admissions and/or ED utilization. The RN Ambulatory Care Coordinator will collaborate with Primary Care providers, PCP office Care Team, Practice Manager, community providers, as well as Care Transition and Acute Care Case Management teams, to best serve the needs of the patient panel and the primary care teams. The Nurse Coordinator will be responsible for collaborating with patients, providers and caregivers in developing a plan of care, documentation of aspects of Ambulatory Care Coordination (ACC) patient care, reviewing and utilizing appropriate patient care reports, and communication of ACC program aspects with primary care providers served.

Essential Functions & Responsibilities:

It is expected that all of the Essential Functions and Responsibilities identified below will be performed in a manner that reflects the values of Mercy Health, which are: Excellence, Human Dignity, Justice, Compassion, Sacredness of Life and Service.

RN Care Coordinator actively manages a panel of Population Health patients by performing these main responsibilities:

  • Collaborating with patient, Primary Care provider and other members of the care team in developing and monitoring a plan of care
  • Working with patient and patient’s care team to coordinate change readiness, needs, assessment, and develop an individualized plan of care.
  • Assisting patients in setting SMART goals for self-management.
  • Educating the patient about self-management tasks, including but not limited to self-monitoring and problem solving so the patient can gain confidence and greater control of their health status.
  • Collaborating with the patient, Primary Care provider, and other care team members in assessing the patient’s progress toward individual healthcare goals.
  • Assessing barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments and communicating these to the Primary Care provider and other care team members.
  • Overseeing the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
  • Refers patient to appropriate internal and community based resources based on need.
  • Coordinating referral to and communication with specialists as needed.
  • Collaborating with payer case managers for additional services when appropriate.
  • Anticipating the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.
  • Collaboration with Care Transitions Team to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physician, or by another healthcare provider.
  • Support post discharge care of patient and assess understanding of post discharge care instructions.
  • Assess medication adherence.
  • Facilitate post-discharge follow up appointments as appropriate.
  • Facilitate post-discharge transitions from Skilled Nursing facilities.
  • Providing telephone advice per protocol, handling urgent calls and emergent calls.
  • Maintains accurate and consistent documentation using the prescribed tools within the electronic health record to ensure use of searchable and reportable fields.
  • Participates in case reviews as assigned by ACC Leader.
  • Collaborates effectively as a care team member
  • Collaborates with Primary Care provider to identify at risk members utilizing multiple available tools.
  • Collaborates with the Primary Care provider and care team members by sharing community resources available to patients and maintaining collegial relationships with the entities used most frequently.
  • Establish communication processes with ACC team, Primary Care providers served and care team members including but not limited to regular cadence of collaborative meetings, attendance at team meetings and huddles, and appropriate routing of documentation.
  • Collaborates with ACC leader to identify outcome measures, prepare and analyze outcomes reports, and progress toward program goals as directed.

Knowledge, Skills & Experience Required:

  • Current RN licensure with BSN preferred, and at (3) years clinical practice experience with demonstrated critical thinking ability. The ideal candidate will have well rounded clinical experiences including work in acute and/or outpatient settings.
  • Strong skills in independent problem solving and process management.
  • Highly organized and detail oriented.
  • Strong interpersonal skills and ability to work collaborative with patients, physician/providers, non-clinical staff, clinical staff, community providers and project teams.
  • Effective oral and written communication skills, communicates information correctly.
  • Self-directed, self-starter and able to implement new programs.
  • Effectively provide education to physicians and staff.
  • Experience with clinical pathways, data analysis, and health care operations.
  • Understanding and/or experience in coaching and motivational interviewing.
  • Experience with electronic medical records and personal computer skills.
  • Accepts responsibility and follows through on projects and activities.
  • Ability to analyze and present patient cases accurately and effectively.


Physical Requirements

  • Energetic and able to drive a car
  • Sight and dexterity to operate a PC, copy machine and telephone.
  • Able to speak well and clearly over a phone and at large group presentations.

Mental Requirements

  • Remains calm during stressful periods and acts appropriately.
  • Ability to quickly learn new skills and concepts.
  • Able to adapt to change.
  • Able to handle multiple priorities at once.
  • Concentration, reasoning and problem solving skills.

Working Conditions

  • Medical staff office or office environment





Day Shift, 8:00 a.m. to 5:00 p.m.

40 Hours Per Week

Equal Employment Opportunity

It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.