Registered Nurse Care Coordinator - First Shift

Registered Nurse Care Coordinator – Full Time First Shift

Join Valley Health as a Registered Nurse Care Coordinator. This full‑time, first shift position focuses on coordinating care for patients, ensuring high‑quality, patient‑centered outcomes.

• Collaborate with providers and clinic staff to identify and prioritize patients appropriate for care coordination services, utilizing care coordination criteria.
• Perform initial, holistic assessments for care coordination population; prioritize patients according to intensity, need, and required follow‑up. Delegate periodic care coordination to an LPN Care Coordinator when appropriate.
• Provide education regarding disease management based on current best‑practice standards. Triage patients escalated for reevaluation by the LPN Care Coordinator.
• Knowledge of federal, state, and local programs and eligibility requirements to proactively connect patients with appropriate resources.
• Develop a care coordination plan and goals mutually agreed upon by patient/family; use motivational interviewing techniques to assist patients in meeting action‑oriented goals and objectives.
• Evaluate effectiveness of plan in meeting established care goals, revise as needed. Collaborate with an LPN Care Coordinator for goal revision when necessary.
• Interact professionally with patient/family to achieve maximum levels of wellness and independence.
• Perform initial calls for patients recently discharged from the hospital who are high risk for readmission. When working with an LPN Care Coordinator, delegate weekly follow‑up calls until the patient has been discharged for 30 days; ensure follow‑up appointments and medication adherence. Provide patient education regarding hospital diagnosis and identify changes in condition, escalating care to provider or EMS as appropriate.
• Conduct face‑to‑face patient visits to update medical/surgical/family history, review current medications and allergies, assess social determinants of health, provide health screenings, assess functionality, and review medical record for gaps in care. Conduct shared decision‑making conversations with patient to close care gaps; report findings to provider.
• Assist patients in developing advanced care planning.
• Serve as liaison to providers, patients and families for coordination of services.
• Maintain EMR databases on the care‑managed population; maintain accurate and timely documentation and billing. Triage patients escalated by LPN Care Coordinator for review/updating of care plan; revise care plan at least once per year according to CMS standards.
• Review utilization and quality reports routinely, scan for gaps in care and identify patients needing additional support of care management.
• Participate in regular team meetings, departmental and organizational committees, orientation of new personnel, and provide mentorship to peers.
• Meet with Manager of Population Health Outpatient Care Coordinator and LPN Care Coordinator to provide patient updates, identify issues, and develop resolution strategies.
• Perform all duties in accordance with professional nursing principles, ensuring documentation meets current standards and policies.
• Attend conferences, workshops, and complete continuing education as assigned.

• BSN in Nursing required.
• 3+ years relevant nursing experience, including a minimum of 2 years in nursing case management, preferably with older patients.
• Previous navigation experience in outpatient setting, case management, or home health/public health is required.
• Case management certification required within 2 years of hire.
• Registered Nurse license required; BLS certification required (AHA‑approved). Case management certification preferred.
• Knowledgeable in stages of human growth and development for adult and geriatric populations.
• Strong interpersonal and communication skills; ability to work independently and as part of a multidisciplinary team.
• Knowledge of funding, resources, clinical standards and outcomes for population health.

• A zero‑deductible health plan.
• Dental and vision insurance.
• Generous paid time off.
• Tuition assistance.
• Retirement savings match.
• Robust employee assistance program.
• Membership to Healthy U: an incentive‑based wellness program.
• Health savings account, flexible spending account for childcare, life insurance, short‑term and long‑term disability, and professional development options.
• Perks such as discounts to on‑campus dining and other local benefits.

Registered Nurse license required. BLS certification (AHA‑approved) required. New hires must obtain AHA appropriate certification before orientation. Case management certification preferred.

Warren County, VA. Salary range: $34,000–$48,000 (subject to experience). Additional locations listed:
Woodstock, VA;
Winchester, VA;
Front Royal, VA.