Community Care Team Registered Nurse (RN)

Penobscot Community Health Care•Old Town, ME

2d•$64,480 - $92,102•Onsite

About The Position

The Community Care Team RN plays a vital role in improving outcomes for patients with complex medical and social needs through compassionate, community-based care coordination and advocacy. In partnership with Care Management leadership and an interdisciplinary network of providers, social workers, care managers, families, and community organizations, this RN will support patients across the care continuum—helping them navigate the healthcare system, access critical resources, and achieve greater stability and wellness. This is an ideal opportunity for a mission-driven nurse who thrives in collaborative environments and is passionate about delivering patient-centered, population-focused care. This position works in a Designated Healthcare Facility which is subject to the State of Maine’s immunization requirements for healthcare workers. If hired, you will be required to show a Certificate of Immunization, or Proof of Immunity, against: 1.) Rubeola (measles); Mumps; Rubella (German measles); Varicella; Hepatitis B; and Influenza.

Requirements

Must have a valid RN degree with an active, unrestricted license in Maine or a state that is part of the Nurse Licensure Compact.
Minimum of three years of nursing experience in adult, primary care, community health, care management, or related healthcare settings required, including experience supporting patients with chronic or complex medical needs.
Will have up-to-date training and certification in Healthcare Provider Basic Life Support issued by American Heart Association, American Red Cross, or American Health & Safety Institute. Must obtain within 2 weeks if not current at hire.
Having a valid driver’s license with an acceptable driving record and/or an appropriate length of driving experience for insurance purposes is required. Any concerns raised by the results of a driving record check will be subject to an individualized review to determine whether the infraction is relevant to the individual’s ability to perform the responsibilities of the position in accordance with PCHC’s Automobile Safety and Background Check Policy.

Nice To Haves

Experience in population health, transitional care management, or interdisciplinary care coordination preferred.

Responsibilities

Community-Based Care Coordination: Partner closely with primary care providers, hospitals, specialists, behavioral health professionals, social workers, and community partners to deliver comprehensive, patient-centered care management services across a variety of settings.
Advocacy & Patient Navigation: Serve as a trusted advocate for patients and families by helping coordinate appointments, referrals, preventive care, medication access, and transitions between healthcare settings while addressing barriers that impact care and outcomes.
Population Health Impact: Support high-risk and medically complex patients through proactive outreach, chronic disease education, care gap management, and transitional care efforts designed to reduce avoidable hospital utilization and improve long-term health outcomes.
Holistic, Individualized Care Planning: Conduct comprehensive assessments and develop personalized care management plans that reflect each patient’s clinical, psychosocial, behavioral health, and social determinant of health needs.
Collaborative & Mission-Focused Team Environment: Works as part of a multidisciplinary team committed to improving patient experience, advancing health equity, and strengthening access to community resources through coordinated, compassionate care.
Professional Expertise & Growth: Bring your clinical judgment, relationship-building skills, and care coordination experience to a role that values autonomy, critical thinking, and continuous improvement in community and population health initiatives.