Registered Nurse of Complex Care Coordination

Sun River Health•Monticello, NY

6d•Hybrid

About The Position

The Complex Care Coordination RN is a hybrid registered nurse based out of Monticello, New York, supporting timely, appropriate, and cost-effective care for patients across multiple Hudson Valley sites. The RN provides telephonic triage, chronic disease management support, post-discharge outreach, and coordination of timely follow-up, partnering with on-site clinical teams and extending nursing capacity at sites without dedicated care-coordination staff. The position prioritizes patients with complex chronic conditions in rural HV North locations and supports sites with limited staffing. Using evidence-based protocols, the RN assesses symptoms, identifies and escalates red-flag findings, closes care gaps, reinforces patient self-management, and coordinates care across primary care, specialty, hospital, home-health, and community-service partners. The role is accountable for value-based care outcomes, health center access metrics, and the quality, safety, and documentation of clinical encounters. Sun River Health’s mission is to increase access to comprehensive primary and preventive health care and improve the health status of the community, especially underserved and vulnerable people. The organization provides equal employment opportunities and considers reasonable accommodations for applicants and employees with disabilities in accordance with applicable law.

Requirements

Current, unencumbered Registered Nurse license in New York State.
Associate degree in nursing considered; a BSN is preferred.
Current CPR/BLS certification.
Proficiency with electronic health records and standard office productivity tools.
Comfort with telehealth technology and secure remote communication.
Strong clinical assessment, critical-thinking, and prioritization skills in a remote, high-volume environment.
Excellent verbal and written communication skills and ability to build rapport with patients and cross-site teams in person, by phone, and by video.

Nice To Haves

Care coordination, care management, transitions-of-care, or telehealth/triage experience is strongly preferred.
Experience with chronic disease management, including CHF, diabetes, and hypertension, and evidence-based patient education.
Cultural humility and experience serving diverse, underserved, and rural communities.
Bilingual English/Spanish.

Responsibilities

Serve as a remote care-coordination resource for assigned HV North sites, partnering with providers, nurses, medical assistants, and care managers to close care gaps and support continuity across settings.
Identify inpatient, skilled nursing facility, emergency department, and behavioral health discharges within 24–48 hours of notification and initiate structured post-discharge outreach.
Conduct telephone medication reconciliation and renewals according to Sun River Health protocols.
Support health centers with telephone encounters, symptom and access-barrier assessment, follow-up appointment engagement, and warm handoffs to internal programs, durable medical equipment, transportation, and social services when indicated.
Integrate patient assessments and engagement with site primary care teams through appropriate communication channels.
Coordinate longitudinal care with primary care, specialty, hospital, home-health, and community-service partners; transfer information to site care teams through the EHR and closed-loop communication.
Support prior authorizations, referrals, and clinical follow-up when local site capacity is limited.
Track and meet Transitional Care Management and Complex Care Coordination requirements where applicable for reimbursement of eligible services.
Provide telephone education about medications, symptom management, self-care, and appropriate use of urgent and emergency services.
Identify red-flag symptoms and promptly escalate findings to a provider, on-site RN, or emergency services in accordance with organizational pathways.
Conduct structured symptom assessments, apply clinical judgment within RN scope of practice, and recommend an appropriate level of care.
Maintain accurate, real-time documentation of coordination activities in the electronic medical record.
Perform the general duties and responsibilities necessary for the essential functions of the role; specific duties may change based on organizational needs.