HSHS Medical Group
Send this job to a friend
Location: Mt Zion, IL
Department: Advanced Medical Home
Schedule: Full Time
Shift: Day Shift
Hours: M-F 8a-4:30p
Job Details:
  • Basic Function: Under the general direction of the Advanced Medical Home Project Manager, serves in an expanded nursing role to collaborate with defined high-risk patient populations and the Primary Care Providers to implement and manage the HSHS Medical Group medical home. Assesses, plans, implements, navigates, monitors and evaluates all options and services. Integrates evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of patient-centric treatment plans, promoting quality and efficiency in the delivery of healthcare.


    1. Graduate of an accredited nursing program with a current license to practice as a Registered Nurse in the state of Illinois 
    2. 3 to 5 years of clinical experience working in a hospital, medical office, or clinic setting required
    3. 2 to 4 years of clinical experience in ICU, Home Health or Case Management area preferred
    4. Demonstrated excellent communication skills • Demonstrated exceptional customer service skills

    Principle Responsibilities: 

    1. Works with HSHS Medical Group leadership in the design, implementation, and evaluation of the medical home care model.
    2. Identifies the targeted population within his/her practice site and risk stratifies all patients to prioritize needs and direct interventions.
    3. Assesses the healthcare, educational and psychosocial needs of the member/family. 
    4. Designs an individualized plan of care and fosters a team approach by working collaboratively with the member, family, primary care provider, and other members of the team to navigate the patient through the care continuum.
    5. Implements clinical interventions based on risk stratification and evidence-based clinical guidelines. 
    6. Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner. Provides appropriate follow-up and monitoring as needed.
    7. Coordinates appropriate laboratory and diagnostic testing.
    8. Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned populations.
    9. Coordinates referrals and other community resources.
    10. Implements systems of care that facilitate close monitoring of high-risk populations to prevent and/or intervene early during acute exacerbations.
    11. Maintains required documentations for all nurse navigator activities.  Collects required data and utilizes data to adjust treatment plans when indicated.
    12. Reviews current literature regarding effective engagement and communication strategies to enhance the Medical Home care model.
    13. Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
    14. Attends medical home related meetings as requested.

back to top