Registered Nurse, Care Coordinator

Reports to: Manager, Nursing

Position Overview

The Registered Nurse, Care Coordinator, serves as a core member of the care team, coordinating and supporting healthcare within MIT Health and managing referrals for services outside the clinic. The role includes providing outreach and enrollment services to ensure patients meet program eligibility requirements in surrounding counties. This position ensures effective coordination and planning, with emphasis on community and family support. The case care coordinator is responsible for developing and implementing community service plans and collaborating with the primary Care multi-disciplinary, families, and patients to design individualized healthcare plans and connect patients with additional resources as needed.

Principal Duties and Responsibilities*

• Collaborate with Primary Care providers to identify patients who may benefit from care coordination support.
• Establish patient care goals through education, information, and guidance for patients and families.
• Develop individualized healthcare plans in partnership with service providers, families, and patients.
• Ensure coordination and continuity of care, including engagement with community resources and family support.
• Follow up with at-risk patients after inpatient admissions or emergency/urgent care visits, ensuring home services and follow-up appointments are arranged.
• Maintain close communication with the Primary Care team to ensure consistency in care planning.
• Maintain accurate, detailed, and up-to-date reports and records.
• Acquire and maintain knowledge of available patient services, insurance benefits, and reimbursement processes.
• Arrange for community services such as home care and elder services, and intervene when service availability or quality issues arise.
• Act as a resource and advocate for patients, clinicians, and families to ensure appropriate care and services.
• Assist patients in navigating access to MIT Health services and external specialists, including mental health resources.
• Collaborate with the Primary Care nursing team as needed.
• Stay informed on current research related to ambulatory nursing and care coordination, and contribute to program development.
• Perform other duties as assigned.
  
  

Minimum Required Education And Experience

• Graduate of an accredited nursing program. Bachelor’s degree required.
• Licensure: Current RN license in Massachusetts. CPR Certified.
• Minimum 3 years as a Registered Nurse in pediatrics, women’s health, or family medicine ambulatory clinic or private practice setting.
• 2 years of case management, utilization review, and discharge planning experience preferred.
• Strong knowledge of care coordination, discharge planning, and community health resources.
• Excellent communication, organizational, and documentation skills.
• Ability to work collaboratively with patients, families, providers, and community agencies.
• Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access. Fluency with EMR systems, Cerner
  
  

Job number: 25320

Grade level: 9

Pay Range: $95,000 - $105,000, final salary determined by MIT’s compensation team based on the skills and experience of the person hired

• To comply with regulations by the Americans with Disabilities Act (ADA), the principal duties in job descriptions must be essential to the job. To identify essential functions, focus on the purpose and the result of the duties rather than the manner in which they are performed. The following definition applies: a job function is essential if removal of that function would fundamentally change the job.