RN Care Coordinator

Job Summary: The RN Care Coordinator functions as a registered nurse responsible for developing, implementing, and evaluating care plans for patients requiring intensive care management, with a focus on chronic conditions such as diabetes and hypertension. Working collaboratively with a multidisciplinary care team—including providers, nurses, dietitians, pharmacists, behavioral health clinicians, and community health workers—the RN Clinical Care Coordinator ensures that high-risk patients receive comprehensive and coordinated care. In addition to direct patient care in the clinic, the RN Care Coordinator will also support quality improvement initiatives and projects, administer vaccines and injectable medications, and perform certain diagnostic procedures (e.g., spirometry, diabetic retinal imaging, etc.).

Full time Position: Yes

Reports to: Clinical Pharmacy and Allied Health Manager

Supervises: No

Work Schedule:

Monday through Friday during standard business hours

Times are subject to change due to business necessity

Job Duties, these are considered essential to the successful performance of this position:

• Complete nursing assessments and create care plans for patients with complex chronic disease with an emphasis on diabetes.
• Enroll patients in Remote Patient Monitoring for blood pressure and blood glucose. Monitor patient blood pressure and blood sugar numbers. Communicate with the patient and provider regarding readings.
• Complete outreach calls to patients with suspected medication non-adherence with the goal of improving adherence.
• Complete other interventions to improve medication access and adherence such as prior authorizations, tracking of patients on medication assistance programs and medication refill quality improvement projects.
• Work with the patient, family, and care team to create mutual goals to improve health status.
• Educate patients/family members and use behavior change strategies to improve patient health status.
• Within organizational protocols and nursing scope of practice, assist patients with receiving needed labs, screenings, referrals, other preventative needs, etc.
• Administers intramuscular, subcutaneous, and intradermal injections, including vaccines and prescribed medications, in accordance with clinical protocols and safety standards.
• Performs procedures including, but not limited to, spirometry and diabetic retinal imaging, preparing results for provider interpretation and follow-up care planning.
• Facilitate patient access to internal and external medical and specialty providers.
• Serve as a primary contact, advocate, and educational resource for patients and families.
• Facilitate transition of patients from inpatient and ED.
• Assist providers in women’s health and primary care in handling urgent patient care needs that are above the level of an MA or LPN such as delivering sensitive messages to patients.
• Identify patients to enroll in your case management services by being available to go into exam rooms during provider visits, conducting outreach calls to enroll people, and advocating that providers assist you.
• Participate in Quality Improvement meetings and initiatives.
• Assist in investigating clinical incidents.
• This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

Job Qualifications:

Education: Bachelor's degree in nursing. 

Experience: 0-3 years clinical care experience. Ambulatory or primary care nursing preferred. Hospital-based nursing acceptable. Ideal candidate has case management experience and experience working with patients with chronic diseases or complex health issues. Candidates must have valid driver’s license, reliable transportation, and maintain CPR certification.

Registration/Licensure: Current RN License