Care Coordinator RN

Position Summary

The RN Care Coordinator supports the coordination of clinical objectives for patient referrals while maintaining financial and clinical accountability for Nexus Health Systems referral protocols. This role works collaboratively with both clinical and non-clinical departments to evaluate referrals, optimize payer outcomes, support admission decisions, and contribute to departmental performance objectives.

Essential Duties And Responsibilities

• Evaluate incoming patient referrals and identify appropriate clinical programming and level of care.
• Develop comprehensive clinical summaries to support admission recommendations.
• Review medical records, physician documentation, therapy evaluations, and supporting clinical information.
• Participate in clinical case reviews and live payer reviews as needed.
• Collaborate with Clinical Liaisons to support referral conversion and admission decisions.
• Maintain referral documentation and correspondence within centralized referral tracking systems.
• Identify clinical trends and patterns that may impact referral outcomes and provide recommendations for resolution.
• Support referral evaluation processes and identify opportunities to reduce denials and appeals.
• Aid in denial management efforts and identify root causes of authorization denials.
• Participate in appeals and peer-to-peer reviews involving clinical justification and documentation.
• Research and remain current on Medicare, Medicaid, and Commercial Payer regulations and updates.
• Provide clinical guidance to support payer authorization strategies and reimbursement optimization.
• Afford assistance in identifying barriers impacting referral aging, denials, and write-offs.

Quality & Operational Excellence

• Ensure compliance with all applicable federal, state, payer, and accreditation requirements.
• Participate in quality assurance audits and departmental process improvement initiatives.
• Monitor referral workflows and recommend operational improvements supported by data.
• Afford assistance in correspondence review processes and ensure appropriate action is taken within established timelines.
• Afford assistance in departmental reporting and distribution of key performance metrics.
• Afford assistance in achieving departmental goals and performance indicators.

Collaboration & Customer Service

• Serve as a clinical resource to Admissions, Clinical Liaisons, Utilization Review, and operational leaders.
• Communicate effectively with referral sources, providers, payers, and internal stakeholders.
• Provide exceptional customer service while maintaining professionalism and urgency.
• Participate in departmental meetings and serve as a subject matter expert when appropriate.
• Escalate complex clinical or operational concerns to leadership as needed.