Care Coordinator - RN or LPN

Southwest Virginia Community Health Systems, Inc. (SVCHS) is seeking an experienced and compassionate Care Coordinator (RN or LPN) to join our multidisciplinary primary care team. This position coordinates services for high-risk patients, individuals with chronic illnesses, and patients managing multiple health conditions.

Working within a Patient-Centered Medical Home (PCMH) environment, the Care Coordinator partners with patients, families, healthcare providers, hospitals, specialists, health plans, and community organizations to improve continuity of care. The position plays an important role in reducing avoidable hospital admissions and emergency department visits, addressing barriers to care, and improving health outcomes.

• Pay Range (based on licensure, skills, and experience): $20.00 - $26.00 per hour
• Health, dental, and vision coverage
• Group Term Life insurance
• Voluntary Life Insurance
• Voluntary Accident, Hospital Indemnity, Critical Illness, Short Term Disability, Long Term Disability
• 403(b) Retirement Plan with Employer Contribution
• Paid Time Off

• Use the electronic medical record (EMR), patient registries, risk assessments, and population health reports to identify high-risk patients and care gaps.
• Proactively engage patients and help them maintain a strong connection with their primary care medical home.
• Conduct pre-visit planning and prepare daily huddle reports, risk assessments, and patient follow-up priorities.
• Assist providers and care team members in implementing evidence-based practices for preventive care, chronic disease management, and population health.
• Collaborate with patients, families, and clinical team members to develop individualized plans of care.
• Ensure care plans address preventive screenings, disease-specific interventions, treatment goals, and patient self-management goals.
• Enroll eligible patients in chronic care management programs.
• Develop, review, and update chronic disease care plans in collaboration with patients and providers.
• Track pregnancies through delivery to support Uniform Data System (UDS) reporting requirements.

• Serve as a primary care coordination contact for patients and families.
• Coordinate referrals, specialist appointments, diagnostic testing, follow-up care, and connections to community resources.
• Facilitate timely communication among patients, primary care providers, hospitals, emergency departments, long‑term care facilities, specialists, home health agencies, and insurance plans.
• Develop collaborative relationships with hospital admission staff, case managers, discharge planners, and emergency department contacts.
• Obtain medical records, laboratory results, diagnostic reports, and other clinical information needed to support continuity of care.
• Monitor transitions of care and support timely patient outreach and follow-up, including:
  • Hospital follow‑up appointments within seven days of discharge.
  • Emergency department outreach within 48 hours of discharge.
  • Emergency department follow‑up appointments within 7–14 days of discharge.
• Collaborate with patients, providers, and insurance payers to reduce avoidable emergency department utilization.
• Identify barriers affecting access to care, including transportation, financial, language, health literacy, and social needs.
• Help patients overcome identified barriers by coordinating appropriate services and resources.
• Communicate patient needs, preferences, risks, and barriers to providers and other members of the care team.
• Participate in multidisciplinary care team meetings, case reviews, quality improvement projects, and population health initiatives.