RN Care Coordinator -AMG Connections Center - P/T

Augusta Health•Fishersville, VA

45d•$35 - $54

About The Position

The RN Care Coordinator provides advanced care coordination in the ambulatory setting, using independent nursing judgment for triage, clinical decision-making, management of patient needs, and guidance through the health system. The role serves as a central clinical resource for triage, provider inbox and clinical result management, medication oversight, and support for creating and implementing clinical pathways, policies, and services. The position manages RN-level clinical tasks that promote safe, efficient care and help providers practice at the top of their license. Acting as a patient advocate and liaison among patients, families, providers, and clinical teams, the RN promotes access, education, timely care, and continuity while working with a high level of autonomy within established protocols. The position performs clinical triage and coordinates care transitions; manages provider inboxes, results, and patient communication requiring RN judgment; supports medication and prescription management; coordinates laboratory testing, imaging, diagnostics, and referrals; and collaborates with the care team on patient education, access, quality, and documentation. The role also provides patient education and emotional support, audits EKG follow-up across clinics, and contributes to service-line improvement efforts.

Requirements

Bachelor's degree in Nursing.
Current and valid Registered Nurse license in the Commonwealth of Virginia or in a state that participates in a Compact agreement with Virginia.
CPR certification.
Previous computer experience, including EHR and database applications.

Nice To Haves

Ambulatory Care Nursing Certification (AMB-BC).
Previous ambulatory office experience.

Responsibilities

Perform RN-level clinical triage for patient calls, walk-in encounters, electronic messages, abnormal test results, and referrals using evidence-based protocols, standing orders, and independent nursing judgment.
Assess symptoms, vital sign trends, acuity, comorbidities, and risk factors to determine appropriate disposition, including provider evaluation, nurse visits, outpatient management, urgent care, or emergency department escalation.
Coordinate same-day or expedited care with providers, prioritizing high-risk patients and arranging urgent follow-up when appointments are unavailable.
Provide patient education, clinical guidance, and safety instructions within RN scope of practice, adapting communication to health literacy, cognitive ability, and social circumstances.
Coordinate care transitions after emergency department visits, hospitalizations, procedures, or diagnostic testing, including follow-up planning, medication reconciliation, and education.
Manage assigned provider inboxes, clinical result queues, and patient communication buckets, prioritizing time-sensitive and high-risk items.
Assess inbox messages and abnormal laboratory or imaging results for urgency, clinical significance, and next steps; resolve items within RN scope using approved protocols and standing orders, and escalate as appropriate.
Communicate abnormal test results and provider recommendations to patients, provide education, and coordinate repeat testing, treatment adjustments, referrals, and follow-up.
Escalate complex, high-risk, or out-of-scope findings to providers with clinical summaries, risk assessments, and recommendations; ensure closed-loop communication, documentation, and follow-up.
Review prescription refill requests for appropriate prescribing provider, required follow-up intervals, and medication safety.
Identify medication interactions, contraindications, side effects, adherence concerns, and polypharmacy risks; educate patients and families on safe medication use.
Provide same-day education for patients starting insulin, including administration techniques and individualized written or recorded instructions when needed.
Coordinate and perform nurse visits to assist patients with Continuous Glucose Monitoring device application, setup, and education.
Make RN-directed clinical decisions about temporarily holding medications when indicated, in collaboration with providers and with appropriate follow-up.
Instruct patients to maintain blood pressure, heart rate, and blood glucose logs, assess trends, and escalate concerns.
Work with pharmacies and insurers to resolve prescription issues, including signature clarification, quantity adjustments, refill authorization, and covered therapeutic substitutions.
Order routine laboratory tests and preventive imaging under standing orders and protocols, including tests based on RN clinical phone assessment when appropriate.
Communicate laboratory and imaging results, explain values and provider recommendations, coordinate referrals, and ensure follow-up plans are understood.
Identify and apply clinically appropriate diagnosis codes for laboratory tests, imaging, and referrals to support insurance coverage and reduce barriers to care.
Place, manage, and track internal and external referrals requiring RN clinical assessment; evaluate appropriateness and collaborate with providers when clarification or shared decision-making is needed.
Partner with navigators and support staff to ensure timely scheduling, completion of prerequisites, and follow-through on referrals.
Collaborate with providers, nursing staff, navigators, and front office staff to support safe, efficient, patient-centered workflows and optimize clinic access.
Provide emotional support to patients and families using a holistic, trauma-informed approach.
Audit and review EKGs completed across primary care and multispecialty clinics to ensure appropriate follow-up and provider review.
Identify trends related to access, safety, utilization, or quality and contribute to service-line improvement efforts.
Maintain accurate, timely, and compliant electronic health record documentation to support continuity of care, regulatory compliance, and quality reporting.