Registered Nurse – Care Coordination
About The Position
The Registered Nurse supports care coordination, patient engagement, and clinical oversight for patients receiving enhanced care management and wraparound support services. The role guides care recommendations, supports transitions of care, collaborates with multidisciplinary teams, and helps patients connect with clinical, social, and community-based resources. The position is full-time and hybrid, with availability for in-person visits required, and is limited to San Bernardino or Riverside counties in the Inland Empire. The RN serves as a clinical resource for care coordination programs, supports individualized care planning and patient education, and coordinates follow-up and services for patients with complex medical, behavioral, and social needs. The nurse works within the scope of the California RN license and under appropriate physician oversight, while following HIPAA, company, regulatory, and documentation requirements.
Requirements
- Active Registered Nurse license in California.
- Strong understanding of clinical care planning, patient engagement, and care transitions.
- Knowledge of social determinants of health and community resource navigation.
- Ability to support patients with complex medical, behavioral, and social needs.
- Strong communication, documentation, and organizational skills.
- Comfortable collaborating with physicians, care teams, leadership, and community-based partners.
- Ability to work independently while supporting a multidisciplinary care model.
Nice To Haves
- Experience in care coordination, case management, population health, enhanced care management, or similar patient support programs.
- Knowledge of Motivational Interviewing, Trauma-Informed Care, Harm Reduction, and Stages of Change.
Responsibilities
- Serve as a clinical resource and subject matter expert for care coordination and enhanced care management programs.
- Provide care recommendations within the scope of the Registered Nurse license and under appropriate physician oversight.
- Support clinical assessments that contribute to individualized care plan development.
- Promote patient engagement, education, and follow-through with care plans.
- Conduct telephonic outreach and patient visits as needed based on program needs.
- Support transitions of care, including post-discharge follow-up and engagement with high-risk patients.
- Reinforce provider recommendations and care plans during patient interactions.
- Coordinate services such as primary care, specialty care, labs, durable medical equipment, behavioral health, and community-based resources.
- Assess environmental, social, and functional barriers to care and help coordinate appropriate interventions.
- Participate in multidisciplinary team meetings.
- Collaborate with leadership to support care model improvements.
- Identify and escalate clinical or social concerns to appropriate team members.
- Perform chart audits in accordance with company, regulatory, and compliance standards.
- Maintain compliance with HIPAA, company policies, and documentation requirements.
- Perform other duties as assigned based on program and organizational needs.
Benefits
- Medical, dental, and vision benefits.
- 401(k) plan.
- Three weeks total paid time away, including two weeks and 6–7 company-recognized federal holidays.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
