RN - Coordinator - Care Coordination and Resource Services - Full Time - 8 Hour - Days

About the Role

The RN Coordinator for Care Coordination and Resource Services acts as a patient advocate, assisting patients to achieve optimal function and health in an environment suited to their needs. This role functions within the full scope of nursing practice, extending beyond individual episodes of care to coordinate care across the continuum—from inpatient to outpatient and into the community. The duration of patient follow-up is determined by the patient’s needs and the achievement of care plan goals.

The RN performs cost-benefit analyses of care options, balancing patient needs with available resources, and uses independent judgment to ensure the most appropriate use of resources while reducing unnecessary hospital utilization. The role involves monitoring patients through care transitions to minimize readmission risks and making autonomous decisions regarding risk assessment, care planning, and resource utilization based on established policies and community standards.

Responsibilities

• Coordinate care across the continuum, including inpatient-to-outpatient and community settings.
• Perform cost-benefit analyses of care options to balance patient needs and available resources.
• Utilize independent judgment to assess risks, develop care plans, and allocate resources effectively.
• Monitor patients during care transitions to reduce the potential for readmission.
• Develop and implement care plans for patients with complex medical, emotional, and social needs.
• Serve as a health coach for patients across all categories, from wellness to end-of-life care.
• Motivate, mentor, and redirect clients to achieve compliance with medical, social, and functional interventions.
• Assess and communicate critical information to management and staff to address potential problems.
• Maintain strict confidentiality in compliance with HIPAA and California Confidentiality of Medical Information Act.
• Ensure a safe working environment by adhering to relevant policies and reporting unsafe conditions.
• Participate in internal and external teams and workgroups as needed.

Requirements

• Graduate of an accredited School of Nursing (Required).
• Master’s Degree in Case Management (Preferred).
• 1 year of Care Coordination or Care Management experience (Required).
• Two years of Nursing experience in Ambulatory Services (Required).
• Two years of Nursing experience in Acute Care (Preferred).
• Experience in Ambulatory—Independent Physician Practice (IPA) or Medical Group (Preferred).
• Experience in Health Plan or Care Management Company (Preferred).

Qualifications

• Active RN (Registered Nursing) license from the California Board of Nursing (Required).
• BLS (Basic Life Support) certification from the American Heart Association (Required).
• CCM (Certified Case Manager) certification from the CCMC (Preferred).

Skills

• Proficiency with EPIC (EMR), PC, word processing, Excel, and database programs.
• Strong organizational skills, ability to prioritize, and manage multiple demands under strict timelines.
• Leadership skills to delegate, guide staff, and hold others accountable.
• Ability to communicate respectfully with patients and families from diverse backgrounds.
• Ability to work independently with minimal direction and exercise discretion in decision-making.
• Effective oral and written communication, interpersonal, problem-solving, and conflict resolution skills.
• In-depth knowledge of geriatrics, chronic disease processes, and current treatments.
• General knowledge of common diagnoses, procedures, and life-span development.
• General knowledge of government and private insurance benefits (e.g., Medi-Cal, Medicare, DRGs, managed care).
• General knowledge of available healthcare and community resources for served populations.
• Demonstrated financial awareness to control costs through responsible use of equipment and supplies.

Pay

Hourly pay range: $87.18 - $117.68. Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area.

Schedule

• Work Shift: 08:00 AM - 05:00 PM (Exempt).
• Scheduled Weekly Hours: 40.