RN Coordinator

Martin Luther King, Jr. Community Hospital seeks an RN Coordinator for Enhanced Care Management (ECM) to support complex, high-need patients in South Los Angeles. In this role, you will lead RN-driven assessments, care planning, and coordination across inpatient, outpatient, and community settings, addressing medical, behavioral, and social needs. You will collaborate with a mission-driven, interdisciplinary team to reduce barriers to care, improve outcomes, and advance health equity, providing culturally responsive, compassionate support to an underserved, diverse community.

Responsibilities

• Coordinate Enhanced Care Management (ECM) services for high-need patients across inpatient, outpatient, and community settings
• Conduct comprehensive assessments, care planning, and ongoing monitoring to address medical, behavioral, and social determinants of health
• Serve as primary RN point-of-contact for ECM patients, families, and interdisciplinary care teams
• Collaborate with physicians, social workers, behavioral health, community health workers, and external partners to ensure seamless, patient-centered care
• Track outcomes, document services, and ensure compliance with ECM and hospital quality, regulatory, and documentation standards
• Provide patient and family education on chronic disease management, medications, and community resources
• Identify barriers to care such as housing, transportation, and food insecurity and coordinate appropriate referrals
• Support care transitions, including hospital discharge planning and follow-up, to reduce readmissions
• Contribute to quality improvement initiatives related to population health, care coordination, and health equity
• Model culturally responsive, trauma-informed, and compassionate care aligned with MLK Community Hospital's mission

Required Skills

• Care coordination and case management
• Chronic disease management
• Patient assessment and triage
• Electronic health record (EHR) documentation
• Population health and utilization management
• Knowledge of social determinants of health and community resources
• Interdisciplinary team collaboration
• Patient and family education
• Discharge planning and care transitions
• Regulatory and quality compliance for ECM/Medi-Cal