Registered Nurse Care Coordinator

Registered Nurse Care Coordinator

The Registered Nurse Care Coordinator collaborates with providers and clinic staff to identify and prioritize patients appropriate for care coordination services, utilizing care coordination criteria.

• Performs initial, holistic assessments for the care coordination population.
• Prioritizes patients according to intensity, need, and required follow‑up.
• When working with an LPN Care Coordinator, delegates periodic care coordination as appropriate.
• Provides education regarding disease management based on current best practice standards.
• Triages patients escalated for re‑evaluation by the LPN Care Coordinator.
• Has knowledge of current federal, state, and local programs and their eligibility requirements to proactively connect patients with appropriate resources.
• Develops care coordination plans and goals mutually agreed upon by patient/family, utilizing motivational interviewing techniques.
• Evaluates effectiveness of plans to meet established care goals, revises as needed, and collaborates with LPN Caring Coordinator when necessary.
• Interacts professionally with patient/family to achieve maximum levels of wellness and independence.
• Performs initial calls for recently discharged high‑risk patients, ensures follow‑up appointments are attended, medication adherence, and provides education regarding hospital diagnosis.
• Escalates patients who have a change in condition to provider or EMS services as appropriate.
• Performs face‑to‑face patient visits to update medical/surgical/family history, review medications and allergies, assess social determinants of health, provide health screenings, assess functionality, and review medical records for gaps in care; conducts shared decision‑making conversations and reports findings to provider.
• Assists patients in advanced care planning.
• Serves as liaison to providers, patients, and families for coordination of services.
• Maintains EMR database on care‑managed population and ensures accurate documentation and billing.
• Triages patients escalated by LPN Care Coordinator, reviews and updates care plans, revising at least once per year per CMS standards.
• Reviews utilization and quality reports routinely, scans for gaps in care, and identifies patients needing additional support of care management.
• Participates in regular team meetings, departmental and organizational committees, orientation of new personnel, and mentors peers to promote collaborative teamwork.
• Meets with Manager of Population Health Outpatient Care Coordinator and LPN Care Coordinator team member regularly to provide patient updates, identify issues, and develop strategies for resolution.
• Performs all duties in accordance with professional nursing principles and guidelines.
• Attends conferences, workshops, and completes continuing education as assigned.

Nursing (BSN) is required.

3 years relevant nursing experience including a minimum of 2 years’ nursing case management experience, preferably with older patients; navigation experience in an outpatient setting preferred.

Registered Nurse license required. Must be licensed or eligible to practice pending licensure in West Virginia or Virginia (multi‑state license, Nurse Licensure Compact, or single‑state license valid in West Virginia or Virginia only).

BLS Certification (Basic Life Support) – American Heart ‘Healthcare Provider’ (HCP) – AHA approved required; new hires must have AHA certification prior to orientation.

Case management certification is preferred.

• Experience in navigation, case management, or home health/public health in outpatient setting.
• Knowledgeable in stages of human growth and development for adult and geriatric populations.
• Skills in interpersonal relationships, clinical assessment, group process, and high levels of verbal and written communication.
• Ability to interact with other professionals as part of a multidisciplinary team, demonstrating good judgment and decision‑making skills.
• Self‑directed with proven ability to work independently.
• Knowledge of funding, resources, clinical standards and outcomes for population.

• A Zero‑Deductible Health Plan
• Dental and vision insurance
• Generous Paid Time Off
• Tuition Assistance
• Retirement Savings Match
• A Robust Employee Assistance Program to help with many aspects of emotional wellbeing
• 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
• Discounts to on‑campus dining and other perks of working for the largest employer in the region