Patient Care Coordinator - (RN)

Jane Pauley Community Health Center, Inc.•Kokomo, IN

9d•Hybrid

About The Position

Empowering communities through accessible, inclusive, and compassionate care, this is the work we do every day. At Jane Pauley Community Health Center, every role is connected to something bigger. As a Federally Qualified Health Center (FQHC), we deliver integrated, whole-person care to individuals and families across Indiana, regardless of income or insurance status. Our teams work at the intersection of clinical excellence and community impact, supporting underserved populations while building a culture rooted in collaboration, respect, and growth. Here, you are not just joining a workplace, you are becoming part of a mission that truly matters. We are currently seeking a Patient Care Coordinator (RN) to join our team. This role is ideal for a registered nurse who is passionate about care coordination, patient advocacy, and driving quality improvement. The Patient Care Coordinator works closely with providers, staff, and external partners to ensure smooth care transitions, support chronic disease management, and improve patient outcomes. The Patient Care Coordinator is an essential member of the practice care team, working under the direction of the Practice Manager. This role supports health promotion, disease prevention and management, patient education, nursing care planning, and coordination of care with both internal teams and external facilities. The position is hybrid-remote, with work arrangements tailored to the needs of the RN and JPCHC leadership.

Requirements

Current state licensure as a Registered Nurse (RN) required
Graduation from an accredited nursing program required
Basic Life Support (BLS) certification through AHA required
Strong critical thinking, decision-making, and problem-solving skills
Ability to assess patients without face-to-face interaction
Excellent communication and organizational skills
Knowledge of Indiana Nurse Practice Act

Nice To Haves

Minimum 2 years’ experience in ambulatory, triage, or acute care setting preferred
2–5 years’ experience in chronic disease management, case management, utilization management, or adult acute care preferred
1 year of experience or knowledge of Patient-Centered Medical Home (PCMH) initiatives preferred

Responsibilities

Serve as a patient advocate, helping patients navigate the healthcare system
Provide patient education using evidence-based practice and JPCHC-approved resources
Support patient self-care management of disease and behavior modification interventions
Coordinate continuity of care between primary and specialty providers, hospitals, ERs, and JPCHC teams
Conduct telephonic outreach to patients post-hospitalization, discharge, or ER visit
Manage care transitions for high-risk patients, ensuring timely follow-up appointments
Perform phone triage, medication refills, and prior authorizations within scope of licensure
Document all patient interactions accurately and consistently in the EMR
Participate in quality improvement (QI) initiatives and provide feedback on clinical best practices
Monitor closure of care gaps, quality metrics, overdue labs, and abnormal results
Perform proactive outreach to patients due for preventive screenings
Support pre-visit planning with providers and staff
Assist with data collection, outcomes reporting, clinical audits, and program evaluation related to Patient-Centered Medical Home (PCMH) and Medical Neighborhood initiatives
Serve as a nurse preceptor for newly hired clinical staff or nursing students