Continuing Care Coordinator RN
About The Position
The Continuing Care Coordinator RN works 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, educates patients and caregivers, coordinates interdisciplinary care, monitors patient progress, implements evidence-based guidelines, manages referrals according to local program criteria, and contributes to 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, helps patients navigate the healthcare system, and supports readiness for behavior change and chronic disease self-management. The position monitors adherence to primary care and specialist appointments and works to optimize coordination across the care continuum. Hours are Monday through Friday, 8:00 a.m. to 4:30 p.m., with no weekends or holidays. The position is remote for candidates living in Colorado, Utah, Arizona, Nevada, or Kansas, with a preference for Colorado. In-person attendance at the corporate office in Centennial is required for quarterly meetings.
Requirements
- Associate’s degree in Nursing.
- Two years of relevant experience, or an advanced degree.
- State-issued Registered Nurse license, as applicable to employment.
- Strong assessment and patient/caregiver education skills.
- Expertise in chronic disease management and care coordination.
- Ability to collaborate effectively with healthcare professionals to implement evidence-based guidelines.
- Must live in Colorado, Utah, Arizona, Nevada, or Kansas.
Nice To Haves
- Bachelor of Science in Nursing (BSN).
- Three to five years of relevant experience.
- EPIC experience is highly desired.
- Case management, clinic, or TCM/CCM experience is highly desired.
- Remote or hybrid experience is a plus.
- Preference for candidates living in Colorado.
Responsibilities
- Assess at-risk patients’ needs and design, educate on, document, implement, and evaluate self-management care plans in accordance with applicable state and national 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 the multidisciplinary team.
- Help patients and caregivers navigate the healthcare system to reduce fragmentation, obtain timely care, and access appropriate providers, services, and procedures; anticipate barriers where possible.
- Assess patients’ readiness, motivation, and confidence to change; help identify and overcome barriers; establish short- and long-term chronic disease self-management goals; and empower patients, families, and caregivers to achieve wellness and independence.
- Monitor patients’ compliance with scheduling and attending primary care and specialist appointments, identify nonadherence patterns, 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 according to local program criteria and participate in developing workflows and audits to facilitate seamless transitions of care.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
