Patient Care Coordinator - (RN)

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

1h•Hybrid

About The Position

The RN Patient Care Coordinator is an essential member of the practice care team at The Jane Pauley Community Health Center (JPCHC). Working under the direction of the Regional Nurse Administrator, the coordinator supports health promotion, disease prevention, patient self-management, patient education, nursing care planning, and coordination of care. This is a hybrid remote position. The nurse must be able to report for in-office work as requested or as needed by the organization. Remote work flexibility is determined by organizational needs and the nurse, with specific arrangements outlined in the organization's remote work agreement. The role advocates for patients and coordinates care across primary and specialty providers, supports patients in managing their health, and conducts telephone triage and follow-up outreach. The coordinator also works with patients, families, providers, clinical staff, and pharmacies to address care needs and barriers, support preventive screenings and quality outcomes, and maintain timely, accurate EMR documentation. The position includes participation in quality improvement and, as assigned, precepting and mentoring nursing and clinical support staff. The organization is a Federally Qualified Health Center providing integrated, whole-person care to individuals and families across Indiana regardless of income or insurance status. Its teams support underserved populations in a collaborative, respectful, growth-oriented culture.

Requirements

Graduation from an accredited nursing program; an ADN is required.
Current, unrestricted Registered Nurse license in Indiana or a valid multistate compact license recognized in Indiana.
Current Basic Life Support (BLS) certification through AHA.
At least 1 year of nursing experience in triage, acute care, ambulatory care, case management, or an insurance setting.
Professionalism, initiative, and commitment to patient safety, teamwork, patient experience, and quality improvement.
Critical-thinking skills, sound clinical decision-making, and ability to work with minimal supervision.
Ability to manage competing priorities and respond to urgent patient situations in a fast-paced setting.
Ability to assess patients without face-to-face interaction.
Ability to maintain patient confidentiality and comply with HIPAA and organizational privacy and security policies.
Working knowledge of the Indiana Nurse Practice Act and ability to practice within the scope of RN licensure.
Proficiency with EMR systems, including documentation, order management, and patient messaging.
Working knowledge of Microsoft Office, especially Word and Excel, telephone and virtual communication platforms, and other applications.

Nice To Haves

BSN preferred.
At least two years of experience in chronic disease management, case management, utilization management, or adult acute care.
Experience with telephone triage and transitions of care management.
Experience in or working knowledge of the Patient-Centered Medical Home model.
Experience with quality measures such as HEDIS and UDS.
Certification in ambulatory care nursing or case management.

Responsibilities

Serve as a patient advocate and help patients navigate the healthcare system.
Provide patient education tailored to individual needs using evidence-based practices and approved resources.
Encourage active patient engagement in healthcare and support disease self-management through behavior modification interventions.
Coordinate continuity of care between primary care and specialty providers.
Contact patients by phone after hospitalizations or emergency department visits to support continuity of care, reduce readmissions, and prevent avoidable hospital stays.
Conduct telephone triage within the scope of licensure using age-appropriate clinical assessment and approved protocols.
Work with providers, clinical support staff, and pharmacies to manage refill requests under established protocols and resolve prior authorization barriers.
Maintain accurate, complete, and timely EMR documentation of patient encounters, calls, and outreach attempts in accordance with the nursing process and organizational standards.
Partner with patients, families, and interdisciplinary providers to manage an assigned high-risk population, reinforce care plans, and resolve barriers to adherence.
Conduct proactive patient outreach to support completion of recommended preventive screenings.
Participate in clinical quality improvement initiatives and committees.
Precept newly hired nurses and nursing students as assigned.
Serve as a clinical resource and mentor to nursing and clinical support staff by sharing expertise, answering questions, and modeling best practices.