Registered Nurse Care Coordinator - First Shift

Registered Nurse Care Coordinator - Full Time First Shift

Innovate patient-centered care coordination at WMH FRIMA-RHC. This full-time role coordinates comprehensive care for patients, ensuring seamless transitions and optimal health outcomes.

• Collaborate with providers and clinic staff to identify and prioritize patients appropriate for care coordination services based on established criteria.
• Conduct initial, holistic assessments for care coordination population, prioritizing patients by intensity and need; delegate periodic care coordination to an LPN when appropriate.
• Provide education on disease management using current best‑practice standards; triage patients escalated for re‑evaluation by an LPN.
• Utilize knowledge of federal, state, and local programs to connect patients with qualifying resources.
• Develop mutual care‑coordination plans and goals, employing motivational interviewing and helping patients set action‑oriented outcomes.
• Continuously evaluate the effectiveness of care plans, revising them as needed and collaborating with an LPN when plan or goal adjustments are required.
• Maintain professional, family‑centered interactions to promote maximum wellness and independence.
• Follow‑up high‑risk patients after hospital discharge, ensuring medication adherence, appointment attendance, and providing disease‑specific education; elevate care to provider or EMS when condition changes.
• Conduct face‑to‑face visits to update medical histories, medications, allergies, social determinants of health, and health screenings; identify and close care gaps through shared decision‑making.
• Assist patients in advanced care planning and serve as liaison for coordination of additional services.
• Document and manage EMR data for the care‑managed population, ensuring accurate, timely billing and annual care‑plan revisions per CMS standards.
• Review utilization, quality reports, and performance indicators, identifying patients who may need additional care‑management support.
• Participate in regular team meetings, departmental committees, new‑personnel orientation, peer mentorship, and collaborative teamwork initiatives.
• Meet regularly with the Manager of Population Health Outpatient Care Coordination and, if applicable, the LPN Care Coordinator team to update on patient progress, address issues, and develop solutions.
• Adhere strictly to professional nursing principles and documentation standards.
• Continue professional development through conferences, workshops, and mandatory continuing education.

• Bachelor of Science in Nursing (BSN) required.
• At least 3 years of relevant nursing experience, including a minimum of 2 years in case management—preferred with older adults.
• Experience in navigation, case management, or home health/public health is required.
• Case‑management certification required within 2 years of hire.
• Knowledge of adult and geriatric human development, interprofessional collaboration, advanced decision‑making, and independent practice.
• Excellent verbal and written communication, interpersonal skills, and group facilitation.
• Proficiency in federal, state, and local funding and resource programs.

• Registered Nurse license (current) in either West Virginia or Virginia, or a multi‑state license under the Nurse Licensure Compact.
• BLS (Basic Life Support) certification required—American Heart Association or equivalent.
• Case‑management certification preferred.
• New hires must obtain AHA certification prior to orientation.

• Zero‑deductible medical, dental, and vision plans.
• Generous paid time off and holiday pay.
• Tuition assistance and a 401(k) plan with employer match.
• Employee Assistance Program for emotional well‑being.
• Healthy U wellness program membership.
• Health Savings Account, Flexible Spending Accounts, life insurance, and disability coverage.
• Discounts at on‑campus dining and other regional benefits.