Care Coordinator

About the Role

The Registered Nurse Care Coordinator is responsible for the overall care coordination of medically complex patients. This includes managing medical care, providing education, handling internal and external referrals, and connecting patients with community resources. The Care Coordinator works with patients to develop a patient-centered plan of care tailored to their individual needs and self-management goals. The role involves active collaboration with diverse healthcare teams and local community partners to improve patient health outcomes.

Key Responsibilities

• Performs the nursing process (assessment, planning, implementation, evaluation) to develop patient-centered plans of care for medically complex patients.
• Acts as an advocate and actively collaborates with the healthcare team.
• Assists patients navigate the healthcare system and community as a patient care coordinator.
• Facilitates health and disease patient education through individual teaching and group classes.
• Supports patient self-management of disease and behavior modification interventions.
• Assures home monitoring and patient knowledge align with the treatment plan.
• Coordinates continuity of patient care with internal and external healthcare providers.
• Attends clinic, field, and home visits to monitor patient progress and assess needs.
• Manages high-risk patient care, including patients with multiple co-morbidities or a high risk for readmission.
• Promotes clear communication within the care team and with treating clinicians regarding patient care plans.
• Facilitates patient medication management through the medication reconciliation process.
• Connects patients to community resources based on Social Drivers of Health assessments.
• Participates in team efforts for data collection, health outcomes reporting, and clinical audits.

Requirements & Tech Stack

• California Registered Nurse (RN) license required upon hire.
• Nevada Registered Nurse (RN) license required within 3 months of hire.
• Basic Life Support (BLS) for Healthcare Providers certification required upon hire.
• Employee will be enrolled in the Resuscitation Quality Improvement (RQI) Basic Life Support (BLS) Entry or Prep Curriculum (depending on previous BLS certification) within 3 months of hire.
• Electronic Medical Record (EMR) proficiency.

Qualifications

• Associate's Degree from a college or vocational school accredited by the National League of Nursing (NLN), Commission on Collegiate Nursing Education (CCNE), or equivalent.
• Nursing education program must have included clinical experiences with actual patients under the supervision of qualified faculty.
• 6 months to 1 year of relevant experience.
• Self-disciplined, energetic, passionate, and innovative.
• Collaborative team member who follows systems and protocols.
• Highly organized with well-developed oral and written communication skills.
• Demonstrates sound judgment, decision-making, and problem-solving skills.
• Ability to maintain confidentiality in accordance with practice, State, and Federal regulations.
• Confidence to communicate and outreach to other community healthcare organizations.
• Awareness of community resources.
• Demonstrated computer skills.