What are the responsibilities and job description for the RN - COORDINATOR position at East Liberty Family Health Care Center?
Position Summary
The RN Care Coordinator is a key member of the primary care team, responsible for delivering comprehensive, patient‑centered nursing care and care coordination services across ELFHCC's four clinic locations. This role supports providers by managing preventive screenings, coordinating specialty referrals, ensuring continuity of care, providing patient education, and supporting quality‑improvement initiatives within the primary care setting.
The RN serves as a central liaison between patients, providers, external specialists, and community resources, helping patients navigate the healthcare system and achieve improved health outcomes.
Responsibilities
Clinical Nursing Support
Required
ELFHCC offers a competitive, comprehensive benefits package designed to support the wellbeing of our employees and their families. Benefits for full‑time staff include:
Health & Wellness
The RN Care Coordinator is a key member of the primary care team, responsible for delivering comprehensive, patient‑centered nursing care and care coordination services across ELFHCC's four clinic locations. This role supports providers by managing preventive screenings, coordinating specialty referrals, ensuring continuity of care, providing patient education, and supporting quality‑improvement initiatives within the primary care setting.
The RN serves as a central liaison between patients, providers, external specialists, and community resources, helping patients navigate the healthcare system and achieve improved health outcomes.
Responsibilities
Clinical Nursing Support
- Perform patient assessments, triage calls, and support provider-directed care plans.
- Provide patient education on chronic disease management, medications, preventive health, and wellness.
- Assist with vaccine administration, point‑of‑care testing, and clinical procedures within RN scope.
- Manage preventive screening outreach (e.g., colorectal cancer screening, annual wellness reviews, chronic disease monitoring).
- Track test results and ensure timely patient follow-up.
- Coordinate referrals to specialists, including cardiology, endocrinology, behavioral health, and other community partners.
- Support transitions of care after hospitalizations, ED visits, or specialty care.
- Help patients address barriers such as insurance, transportation, appointment access, and understanding care plans.
- Collaborate with Case Management and Social Services when higher-level support is needed.
- Promote trauma‑informed, culturally sensitive care in every patient interaction.
- Support quality initiatives and UDS metrics (e.g., hypertension control, diabetes A1C control, immunizations).
- Participate in chart audits, care-gap closure efforts, and interdisciplinary huddles.
- Assist in workflow development and implementation to improve patient experience and clinical efficiency.
- Maintain accurate documentation within the electronic health record (EHR).
- Follow all ELFHCC policies, nursing standards of practice, and HIPAA regulations.
Required
- Current Registered Nurse (RN) license in the state.
- CPR/BLS certification.
- Experience in primary care, ambulatory care, community health, or a related setting.
- Experience in community health or an FQHC environment.
- Familiarity with preventive care guidelines (USPSTF, CDC, ADA, AHA).
- Knowledge of trauma‑informed and culturally sensitive care practices.
ELFHCC offers a competitive, comprehensive benefits package designed to support the wellbeing of our employees and their families. Benefits for full‑time staff include:
Health & Wellness
- Medical, dental, and vision insurance with employer contributions
- Employer-paid life insurance and disability coverage
- Access to employee assistance resources and wellness programs
- Generous PTO accrual based on years of service
- Paid holidays
- Paid sick time
- Paid jury duty and bereavement leave
- 403(b) retirement plan with employer match
- Flexible spending accounts (healthcare and dependent care)
- Eligibility for Public Service Loan Forgiveness (PSLF) as an FQHC employer
- Continuing education opportunities
- Paid trainings, certifications, and professional development support
- Opportunities for cross-site training and advancement within the organization
- Mission-driven, community-focused work environment
- Supportive interdisciplinary team
- Employee recognition and staff wellness initiatives