RN Care Coordinator - IMA Medical Group

Millennium Physician Group•Lakeland, FL

1d•$77,417 - $116,126•Hybrid

About The Position

The RN Care Coordinator supports patients experiencing emergency department visits and hospital inpatient admissions by coordinating care across hospitals, primary care providers, patients, caregivers, and interdisciplinary care teams. The role facilitates timely transitions of care, identifies clinical and social barriers, provides patient and caregiver education, and coordinates follow-up services to improve outcomes and reduce avoidable emergency department visits and hospital readmissions. The position includes remote coordination and on-site visits to local hospitals and primary care clinics.

Requirements

Degree in Nursing.
At least 3 years of experience in a hospital and/or clinic setting.
Valid Registered Nurse (RN) license in the state of Florida.
CPR/BLS certification.
Strong clinical knowledge and skills, with the ability to make critical decisions in fast-paced settings.
Excellent communication and interpersonal skills.
EMR experience.
Proficiency with Microsoft products, including Teams, Outlook, Excel, Word, and PowerPoint.

Nice To Haves

Experience with Athena EMR.
Bilingual in English and Spanish.
Experience in care management workflows, including transitions of care.
Experience in value-based care, Medicare Advantage, or population health.
Knowledge of CMS, HEDIS, and Medicare Star Ratings quality measures.

Responsibilities

Review hospital portals and Health Information Exchange (HIE) reports daily to identify and monitor inpatient admissions, emergency department visits, transfers, and discharges.
Review clinical information, assess patient risk and care needs, and identify clinical, medication-related, and social barriers that may contribute to avoidable utilization or readmission.
Conduct hospital visits and initial and ongoing patient follow-up during inpatient admissions and emergency department encounters, as appropriate to patient needs.
Coordinate transitions of care beginning during hospitalization, including discharge planning, follow-up appointments, medication management, home health, durable medical equipment, specialty referrals, and other post-acute services.
Collaborate with hospitalist teams, primary care providers, clinic Care Managers, and other interdisciplinary team members to align treatment plans, address discharge barriers, and support safe transitions of care.
Facilitate timely primary care follow-up and help patients and caregivers access appointments, transportation, and appropriate clinical support.
Educate and support patients and caregivers regarding diagnoses, symptom recognition and management, medication adherence, discharge instructions, and healthcare and community resources.
Reinforce appropriate use of healthcare services, including when to contact the PCP or Care Management team, seek urgent or same-day care, contact the on-call provider, or seek emergency care.
Communicate timely updates about hospitalizations, emergency department encounters, discharge plans, patient status, and follow-up needs to PCPs and appropriate provider and clinical team members.
Participate in clinic huddles and collaborate with providers, Care Managers, and referral coordinators to review high-risk patients, frequent emergency department users, and patients requiring post-discharge support.
Participate in care management department meetings, interdisciplinary discussions, and performance improvement initiatives.
Document encounters, patient interactions, assessments, care coordination activities, outreach attempts, education, referrals, escalations, and follow-up plans accurately and within established timeframes, including same-day documentation when required.
Verify patient demographic and contact information, maintain confidentiality, and follow workflows, documentation standards, HIPAA requirements, regulatory and payer requirements, and organizational policies.
Complete assigned follow-up actions and support goals related to patient engagement, care quality, patient satisfaction, and reduced avoidable healthcare utilization.