Registered Nurse Care Coordinator

Job Description

Registered Nurse Care Coordinator collaborates 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.
• When working with an LPN Care Coordinator, delegate periodic care coordination as appropriate.
• Provide education regarding disease management based on current best‑practice standards.
• Triage patients escalated for re‑evaluation by the LPN Care Coordinator.
• Know current federal, state, and local programs, eligibility requirements, and application process to proactively connect patients with appropriate resources.
• Develop care‑coordination plans and goals mutually agreed upon by patient/family, using motivational interviewing techniques and assisting patient in meeting action‑oriented goals.
• Evaluate effectiveness of plans, revise as needed; collaborate with LPN Care Coordinator for patients needing care‑plan revision.
• Interact professionally with patient/family to achieve maximum levels of wellness and independence.
• Perform initial calls for recent hospital discharges considered high risk for readmission; delegate weekly follow‑up calls until discharge 30 days; ensure patient attends follow‑up appointments and adheres to medications; educate patient regarding hospital diagnosis; identify changes in condition and escalates care to provider or EMS services as appropriate.
• Perform face‑to‑face 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; 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 care‑managed population; keep 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 as applicable; orient new personnel; precept and mentor peers; promote collaborative teamwork.
• Meet with Manager of Population Health Outpatient Care Coordinator and, if applicable, LPN Care Coordinator regularly to provide patient updates, identify issues, and develop strategies for resolution.
• Perform all duties in accordance with professional nursing principles and guidelines.
• Attend conferences, workshops, and complete continuing education as assigned.

Bachelor of Science in Nursing (BSN) is required.

Minimum 3 years of nursing experience, including at least 2 years of case‑management experience, preferably with older patients. Navigation experience in outpatient setting preferred.

• Registered Nurse license required (licensure in West Virginia or Virginia).
• BLS Certification (American Heart Association) required before orientation.
• Case‑management certification is preferred.

• Prior navigation, case‑management, or home health/public health experience.
• Knowledge of stages of human growth and development for adult and geriatric populations.
• Strong interpersonal relationships, clinical assessment, group process, and verbal/written communication skills.
• Ability to work independently and collaborate with multidisciplinary team with good judgment and decision‑making.
• Knowledge of funding, resources, clinical standards, and outcomes for population.

• 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:
  Incentive‑Based Wellness Program
• Health savings account & flexible spending account for childcare, life insurance, short‑term and long‑term disability, professional development
• Discounts to on‑campus dining and other perks