Nurse Care Coordinator - North Charleston, SC

SPCP/Southeast Medical Group•North Charleston, SC

18h

About The Position

Quality Healthcare Development is seeking a Nurse Care Coordinator to develop and implement a comprehensive care coordination program in partnership with the Quality Director. The role supports patients within the Accountable Care Organization (ACO) population to improve care quality and patient outcomes while reducing overall cost of care. The coordinator works with patients, families, providers, healthcare teams, and community resources to ensure coordinated, efficient, patient-centered care across the continuum. The position promotes patient engagement, self-management, shared decision-making, and health literacy. The work includes telephone outreach and occasional office encounters, ongoing communication with an assigned patient caseload, care planning, follow-up after hospital discharge, referrals to community resources, education, and timely documentation. The coordinator monitors care plans and collaborates with patients and healthcare team members to address barriers and improve outcomes. The role also participates in program evaluation and quality improvement and maintains HIPAA confidentiality and awareness of cultural and demographic diversity. Work is primarily in an office/clerical environment with moderate noise and extensive computer use. Duties are primarily telephonic and administrative, with occasional patient encounters in a clinical setting. Annual safety, emergency action plan, and HIPAA compliance training are required. The position is classified as exempt under the professional exemption criteria.

Requirements

Bachelor’s degree in Nursing (BSN) required.
Current Registered Nurse (RN) license in the State of South Carolina required.
Strong interpersonal communication and organizational skills.
Ability to work independently, take initiative, and identify opportunities for professional growth.
Strong critical-thinking and problem-solving abilities.
Ability to quickly assess and prioritize patient needs.
Experience engaging patients through telephone outreach and care management activities.
Comprehensive knowledge of chronic health conditions and clinical assessment parameters.
Strong knowledge of healthcare systems and care navigation.
Flexibility and adaptability in a dynamic healthcare environment.
Proficiency in basic computer applications and electronic medical record systems.
Proficiency in Microsoft Office and general computer systems required.

Nice To Haves

Minimum of five years of experience in a clinical or outpatient setting preferred.
Experience in care coordination, case management, population health, or value-based care preferred.
Experience with Electronic Medical Records (EMR) systems preferred.
Experience with Aprima, ECW, Athena, Greenway, Allscripts, or other population health platforms is a plus.

Responsibilities

Participate in care coordination program development, evaluation, and improvement initiatives.
Conduct patient outreach by telephone and occasional office encounters, and maintain regular communication with patients in the assigned caseload.
Coordinate patient activities and support appropriate utilization of healthcare services.
Support care gap closure and ensure appropriate follow-up care.
Include patients’ family members, caregivers, and support systems in care coordination when appropriate.
Promote patient engagement, self-management, and shared decision-making.
Help patients and caregivers understand condition management, medications, tests, referrals, and recommended services.
Collaborate with patients, providers, and healthcare teams to develop care plans that maximize health outcomes and cost-effective care.
Consult with providers and healthcare team members to address care issues and barriers to treatment.
Coordinate care across the continuum, including post-discharge follow-up calls for hospitalized patients.
Assist patients in accessing community resources and financial assistance when appropriate.
Identify and address barriers to adherence with treatment plans.
Use motivational interviewing and other strategies to promote engagement and improved health outcomes.
Assess and implement strategies to improve patient and caregiver health literacy.
Provide education and resources to support informed healthcare decisions.
Monitor care plan effectiveness and revise plans as needed with patients and the healthcare team.
Accurately and promptly document patient care coordination activities.
Serve as a patient advocate throughout the care coordination process.
Participate in quality improvement initiatives and care coordination program evaluations.
Adhere to HIPAA regulations and patient confidentiality requirements.
Demonstrate awareness of and responsiveness to cultural and demographic diversity within the patient population.