Care Coordinator - RN or LPN

Southwest Virginia Community Health Systems • Bristol, VA

1d • $20 - $26 • Onsite

About The Position

Southwest Virginia Community Health Systems, Inc. (SVCHS) is seeking an experienced and compassionate Care Coordinator (RN or LPN) to join our multidisciplinary primary care team. This position coordinates services for high-risk patients, individuals with chronic illnesses, and patients managing multiple health conditions. Working within a Patient-Centered Medical Home (PCMH) environment, the Care Coordinator partners with patients, families, healthcare providers, hospitals, specialists, health plans, and community organizations to improve continuity of care. The position plays an important role in reducing avoidable hospital admissions and emergency department visits, addressing barriers to care, and improving health outcomes.

Requirements

• Current, unrestricted license to practice as a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
• Minimum of five years of relevant healthcare experience.
• Experience in a health center, primary care practice, rehabilitation setting, skilled nursing facility, home health organization, managed care plan, or comparable healthcare environment.
• Experience with care coordination, case management, discharge planning, transitional care, or chronic disease management.
• Current Basic Life Support (BLS) and CPR certification, or ability to obtain certification within the timeframe established by SVCHS.
• Working knowledge of electronic medical records, patient registries, and clinical documentation.
• Proficiency with Microsoft Office, including Word, Excel, PowerPoint, and Outlook.
• Ability to maintain patient confidentiality and properly manage protected health information.
• Strong organizational, prioritization, follow-through, and time-management skills.
• Ability to communicate professionally and compassionately with patients, families, healthcare professionals, community partners, and the public.
• Ability to work independently and collaboratively as part of a multidisciplinary healthcare team.
• Familiarity with community and social service resources that address patients’ health-related social needs.

Nice To Haves

• Certified Case Manager (CCM) credential.
• Experience working in a Federally Qualified Health Center or Patient-Centered Medical Home.
• Experience using motivational interviewing and patient-centered health coaching techniques.
• Experience with population health management, chronic care management, care transitions, quality improvement, or value-based care.
• Knowledge of Uniform Data System reporting and other health center quality measures.
• Experience working with high-risk, medically complex, or underserved patient populations.

Responsibilities

• Use the electronic medical record (EMR), patient registries, risk assessments, and population health reports to identify high-risk patients and care gaps.
• Proactively engage patients and help them maintain a strong connection with their primary care medical home.
• Conduct pre-visit planning and prepare daily huddle reports, risk assessments, and patient follow-up priorities.
• Assist providers and care team members in implementing evidence-based practices for preventive care, chronic disease management, and population health.
• Collaborate with patients, families, and clinical team members to develop individualized plans of care.
• Ensure care plans address preventive screenings, disease-specific interventions, treatment goals, and patient self-management goals.
• Enroll eligible patients in chronic care management programs.
• Develop, review, and update chronic disease care plans in collaboration with patients and providers.
• Track pregnancies through delivery to support Uniform Data System (UDS) reporting requirements.
• Serve as a primary care coordination contact for patients and families.
• Coordinate referrals, specialist appointments, diagnostic testing, follow-up care, and connections to community resources.
• Facilitate timely communication among patients, primary care providers, hospitals, emergency departments, long-term care facilities, specialists, home health agencies, and insurance plans.
• Develop collaborative relationships with hospital admission staff, case managers, discharge planners, and emergency department contacts.
• Obtain medical records, laboratory results, diagnostic reports, and other clinical information needed to support continuity of care.
• Monitor transitions of care and support timely patient outreach and follow-up, including: Hospital follow-up appointments within seven days of discharge. Emergency department outreach within 48 hours of discharge. Emergency department follow-up appointments within 7–14 days of discharge.
• Collaborate with patients, providers, and insurance payers to reduce avoidable emergency department utilization.
• Identify barriers affecting access to care, including transportation, financial, language, health literacy, and social needs.
• Help patients overcome identified barriers by coordinating appropriate services and resources.
• Communicate patient needs, preferences, risks, and barriers to providers and other members of the care team.
• Participate in multidisciplinary care team meetings, case reviews, quality improvement projects, and population health initiatives.
• Assess patients’ readiness and need for additional self-management support.
• Use motivational interviewing and other patient-centered coaching techniques to help patients establish and achieve realistic health goals.
• Provide education and support related to chronic disease management, medication adherence, tobacco cessation, nutrition, physical activity, and other healthy lifestyle choices.
• Connect patients and families with appropriate community, healthcare, and social service resources.
• Encourage patients to participate actively in their care plans and healthcare decisions.
• Maintain accurate, timely, and confidential documentation in the EMR and applicable patient registries.
• Maintain open and effective communication with providers, clinical teams, and office staff regarding patient status and care coordination needs.
• Attend required training, team meetings, and collaboration sessions.
• Protect patient information and comply with HIPAA, organizational policies, and applicable healthcare regulations.
• Perform other duties as assigned.

Benefits

• Health, dental, and vision coverage
• Group Term Life insurance
• Voluntary Life Insurance
• Voluntary Accident, Hospital Indemnity, Critical Illness, Short Term Disability, Long Term Disability
• 403(b) Retirement Plan with Employer Contribution
• Paid Time Off

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed