Care Coordination, RN - Full Time

About the Role

Responsible for actively participating in the management of patients with complex needs, including conducting telephonic visits for Medicare Wellness, Transitional Care Management, and Chronic Care Management. The role requires developing care plans, assisting in the management of “high utilizers,” and identifying barriers to care to successfully manage patients’ disease states. The incumbent will work with care teams and patients to support efficient, effective, and quality care for the community.

Responsibilities

• Interact with patients telephonically (audio and video) for care coordination, including Medicare Wellness Visits, Transitional Care Management, Chronic Care Management, medication reconciliation, documentation of patient‑reported home vitals, and outreach that supports coding efforts and the closure of quality gaps.
• Assist patients in gaining access to primary‑care and specialist appointments as needed within recommended time frames, following provider protocols and scheduling best practices.
• Participate as an active member of the patient’s care team, collaborating with the patient, family, providers, clinical staff, and outside care entities.
• Develop and implement goal‑driven, individualized patient care plans focused on disease management and patient empowerment; educate patients’ families and caregivers in executing these plans.
• Monitor care plans to review patient progress, revise as necessary, and continue providing education and support.
• Document all encounters and patient‑related discussions, close documentation promptly, and appropriately bill for services rendered.
• Utilize technology to support patient care, including basic knowledge of Microsoft Office Suite and the Epic Healthy Planet suite of products for care coordination.

Work Environment & Physical Demands

Requires physical stamina, cognitive function, and emotional stability to meet the demands of a fast‑paced, highly productive, and often stressful work environment. Manual dexterity is needed for general administrative tasks such as keyboarding. The role involves local travel to hospitals for rounding on patients and meetings, as well as visits to skilled nursing facilities.

Requirements

• Registered Nurse (RN) license for the State of Florida.
• Minimum two years of experience in both inpatient and ambulatory care settings (physician office, hospital, or hospice).
• Proficiency with Microsoft Excel (preferred).
• Excellent listening and interpersonal skills.
• Ability to maintain confidences.
• Flexibility, resourcefulness, and strong problem‑solving abilities.
• Capability to handle multiple tasks simultaneously and set priorities.
• Preferred: Bachelor’s degree and Case Management Certification.

Schedule

Full‑time position.