Overview The RN Care Coordinator collaborates with the First Coast Health Alliance Primary Care teams within each practice to provide health coaching and care coordination. Facilitate and support care progression optimization and utilization by promoting interdisciplinary collaboration and treatment. Plan and prioritize care for individuals and populations of patients, focusing on strategies that will promote optimal health. Demonstrates expertise, current knowledge in nursing care and management of a population of patients with varying complexities. Seek to improve patient, family and health system outcomes through the application of education and preventative care. The RN Care Coordinator utilizes FCHA’s health tool to manage high-risk patients, using real-time data to identify and intervene on patients who could benefit from preventative and active management. Responsibilities Develops plan of care and makes recommendations to primary care physicians, and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum. Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner. Assumes an active role with providers to progress test results, clinical decision making and next level of care decisions. Assesses the educational needs of patients, families and members of the health care team and develops and implements appropriate teaching strategies and/or makes appropriate referrals. Anticipates and identifies barriers to care progression. Identifies readmission risk and contributing factors. Works with patient and providers to overcome barriers. Documents patient data, plan, interventions and outcomes according to department guidelines. Act as a liaison between community resources and the patients by staying informed about changes in local resources and services to provide accurate and up-to-date information. Maintain detailed, accurate and timely records of all client interactions, including assessments, service plans, referrals made, and follow-up activities, using a secure case management system. Facilitate transitions of care to primary care clinics once patient is discharged from the hospital. Perform all other duties as assigned by management within job scope. Qualifications Required education: Associates degree in nursing Required experience: 3 years of nursing experience Preferences: BSN 3-5 years of healthcare, ambulatory care, case management, or care coordination experience Knowledge and experience teaching self-management support skills to patients to help achieve health goals Disease management education required Experience with EMR systems required Nutrition education