Registered Nurse of Complex Care Coordination

Sun River Health•Monticello, NY

6d•$45 - $55•Hybrid

About The Position

The Complex Care Coordination RN (HV Region) is a hybrid registered nurse based in Monticello, New York, who supports timely, appropriate, and cost-effective care for patients across multiple Hudson Valley sites. The RN provides remote nursing support and supplemental clinical capacity, particularly for rural HV North locations and sites with limited staffing, partnering with on-site providers, nurses, medical assistants, and care managers. The role provides telephonic triage, chronic disease management support, post-discharge outreach, and coordination of follow-up care. Using evidence-based protocols, the RN assesses symptoms, escalates red-flag findings, closes care gaps, and reinforces patient self-management education. The position supports outcomes relevant to value-based arrangements and health center access metrics, and is accountable for the quality, safety, and documentation of clinical encounters.

Requirements

Current, unencumbered Registered Nurse license in New York State.
Associate degree in nursing considered; a BSN is preferred.
Experience with chronic disease management, including CHF, diabetes, or hypertension, and evidence-based patient education.
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.
Current CPR/BLS certification.

Nice To Haves

Care coordination, care management, transitions-of-care, or telehealth/triage experience.
Cultural humility and experience serving diverse, underserved, and rural communities.
Bilingual English/Spanish skills.
Bachelor of Science in Nursing (BSN).

Responsibilities

Serve as a remote care-coordination resource for assigned HV North sites and partner with site care teams to close care gaps and ensure 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 organizational protocols.
Support health centers with telephone encounters, symptom and care-access assessment, appointment follow-up, and warm handoffs to internal programs and services such as durable medical equipment, transportation, and social services.
Integrate patient assessments and engagements 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 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 applicable Transitional Care Management and Complex Care Coordination requirements for reimbursement of eligible services.
Provide telephonic education on medications, symptom management, self-care, and appropriate use of urgent and emergency services.
Identify red-flag symptoms and promptly escalate to a provider, on-site RN, or emergency services according to organizational pathways.
Conduct structured symptom assessments, apply clinical judgment within the RN scope of practice, and recommend an appropriate level of care.
Maintain accurate, real-time documentation of coordination activities in the electronic medical record.
Support Sun River Health’s mission to increase access to comprehensive primary and preventive care and improve community health, especially for underserved and vulnerable populations.