RN Embedded Care Coordinator - Foundation Collaborative Care - Full Time - Foundation Medical Partners

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)
• Cook specialty coffee shop - Full Time - Location: Nashua, New Hampshire
• 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