RN Care Coordinator

Crouse Hospital•Syracuse, NY

6d•$58,000 - $72,000

About The Position

The RN Care Coordinator - CCM serves as a proactive patient advocate, educator, and care manager for Medicare beneficiaries enrolled in Chronic Care Management services. This role is grounded in a team-based, patient-centered approach that prioritizes relationship-building, early intervention, and coordination across the care continuum. The RN uses clinical knowledge and care coordination skills to empower patients to manage chronic conditions effectively, reduce unnecessary utilization, and improve quality of life.

Requirements

Current RN licensure in New York State.
Associate's Degree in Nursing; BSN preferred.
Strong interpersonal communication and motivational interviewing skills.
Demonstrated understanding of chronic conditions, medication management, and preventative health.
Experience in case management, population health, or care coordination preferred.
Familiarity with EMR systems and Microsoft Office.
Commitment to cultural humility and sensitivity to diverse populations.

Nice To Haves

BSN preferred.
Experience in case management, population health, or care coordination preferred.

Responsibilities

Serve as the primary point of contact and trusted health advocate for an assigned caseload of Medicare patients with two or more chronic conditions.
Build long-term rapport through monthly outreach calls and routine communication
Conduct thorough assessments of physical, emotional, social, and environmental needs.
Develop and regularly update a comprehensive, patient-centered care plan with measurable goals and interventions, documented in the EMR.
Promote self-management and health literacy through coaching, education, and collaborative goal setting.
Coordinate internal and external services including primary care, specialty care, behavioral health, pharmacy, social services, and community resources.
Prevent avoidable hospitalizations and ER visits through timely follow-up, medication review, and problem-solving interventions.
Support transitions of care by ensuring communication, scheduling follow-ups, and medication reconciliation.
Document all interactions, assessments, and updates per CMS billing requirements.
Actively participate in team huddles, staff meetings, and improvement initiatives.
Maintain productivity standards and contribute to department-wide billable goals.
Assist in supporting new team members and sharing best practices.
Enroll new patients into the CCM program and assess eligibility based on insurance, history, and risk-level.

Benefits

Monday-Friday work week
Supportive team environment
Competitive starting rates based on experience
Annual salary increases
Opportunities for professional growth & stability within a fast-growing Medical Practice
Longevity and consistency of management
Perfect attendance award
Tuition reimbursement program
Employee referral program
Affiliation with Crouse Hospital
Generous Health/Dental/Vision & Life insurance
Flexible spending account or Health savings account - available first of the month following your date of hire
Employee assistance program
15 days of paid time-off within first year of employment
7 paid holidays annually
401k with 4% employer match