What are the responsibilities and job description for the RN Embedded Care Coordinator - Foundation Collaborative Care - Full Time - Foundation Medical Partners position at Southern New Hampshire Health?
Who We Are
Southern New Hampshire Health has been a cornerstone of the region since 1893, delivering high-quality, compassionate care close to home. Anchored by Southern New Hampshire Medical Center—a 188-bed, DNV-accredited hospital in downtown Nashua with a Level III Trauma Center and Level II Special Care Nursery—we are proud to be a five-time Magnet®-designated organization for nursing excellence.
Our system includes over 500 providers across Foundation Medical Partners and affiliated practices. Foundation Medical Partners, our multi-specialty group, spans 70 locations across southern New Hampshire and northern Massachusetts, delivering coordinated, patient-centered care to thousands each year.
About the Job
The RN Embedded Care Coordinator plays a critical role within a primary care practice, focusing on managing care for complex and high-risk patients. This position partners closely with providers and care teams to deliver proactive, coordinated, and patient-centered care that improves outcomes and supports patients in managing their health.
What You’ll Do
Manage a panel of complex patients, developing individualized, longitudinal care plans in collaboration with an interdisciplinary team
Provide chronic disease education and self-management support (e.g., diabetes, COPD, CHF, asthma)
Coordinate care across settings, including hospital discharges, specialty referrals, and pre-visit planning
Conduct patient assessments and interventions in-person, via phone triage, and through telehealth
Proactively manage transitions of care to reduce readmissions and improve continuity
Utilize population health tools and EMR systems to identify and manage patients in need of care coordination
Serve as a liaison between patients, providers, and community resources to ensure seamless care delivery
Support quality improvement initiatives focused on patient safety, outcomes, and access to care
Who You Are / Requirements
Minimum Qualifications
Associate’s Degree in Nursing (ASN) from an accredited program
Active Registered Nurse (RN) license in the state of New Hampshire
Current BLS/CPR certification
2 years of clinical nursing experience in a relevant specialty
Preferred Qualifications
Bachelor of Science in Nursing (BSN) or enrollment in a BSN program
Experience in ambulatory care, case management, population health, or public health
Certification in Ambulatory Care Nursing (RN-BC), Care Coordination (CCTM), or similar
Key Skills & Attributes
Strong clinical knowledge, particularly in chronic disease management
Excellent communication, coaching, and patient education skills
Ability to manage a dynamic caseload of approximately 150 patients
High emotional intelligence, organization, and adaptability
Comfort with EMR systems and data-driven care tools
Why You’ll Love Us
Health, dental, prescription, and vision coverage for full-time & part-time employees
Short-term and long-term disability, life, and pet insurance
Tuition reimbursement
Nursing Student Loan Paydown Program
403(b) retirement savings plan with company match
Continuous earned time accrual
& more!