Continuing Care Coordinator RN

Mountain Region Support • Centennial, CO

5d • $37 - $62

About The Position

The Continuing Care Coordinator RN collaborates with physicians, staff, and healthcare professionals to maintain and improve quality and sustainability within the local market network, with a focus on chronic disease management. The role develops individualized care plans based on nursing assessments, provides patient and caregiver education, coordinates interdisciplinary care, monitors patient progress, and implements evidence-based guidelines. It also manages referrals according to local program criteria and participates in developing workflows and audits to facilitate seamless transitions of care.

The coordinator supports at-risk patients and families with self-management, leads interdisciplinary care for high-risk patients referred to the Continuing Care program, and helps patients navigate the healthcare system. The role assesses readiness for change, supports goal-setting and self-management, monitors appointment adherence, and optimizes coordination across the care continuum.

Requirements

• Associate’s degree in Nursing.
• Two years of relevant experience or an advanced degree.
• State-issued Registered Nurse license, as applicable to employment.
• Expertise in chronic disease management and care coordination.
• Strong assessment and education skills.
• Ability to collaborate effectively with healthcare professionals to implement evidence-based guidelines.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Three to five years of relevant experience.

Responsibilities

• Assess at-risk patients and families and design, educate on, document, implement, and evaluate self-management care plans in accordance with applicable guidelines, policies, procedures, and protocols.
• Lead an interdisciplinary healthcare team in managing high-risk patients referred to the Continuing Care program, facilitating collaboration, communication, and coordination among responsible parties.
• Help patients and caregivers navigate the healthcare system to reduce fragmentation, obtain timely care, and access appropriate providers, services, and procedures; anticipate barriers when possible.
• Assess patients’ readiness and confidence for change, help identify and overcome barriers, set short- and long-term chronic disease self-management goals, and empower patients, families, and caregivers to achieve wellness and independence.
• Monitor members’ compliance with scheduling and attending primary care and specialist appointments, identify patterns of nonadherence, and coordinate needed appointments.
• Optimize care coordination across the care continuum and build and maintain positive relationships with the healthcare team.
• Develop individualized care plans based on nursing assessments, provide patient and caregiver education, coordinate interdisciplinary care, monitor progress, and implement evidence-based guidelines.
• Manage referrals based on local program criteria and participate in developing workflows and audits to support seamless transitions of care.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree