RN Care Coordinator

Waikiki Health•Honolulu, HI

12d•$0 - $79,160•Onsite

About The Position

The RN Care Coordinator works within a multi-disciplinary team to deliver comprehensive, patient-centered care for complex individuals, including high hospital utilizers and those with Social Determinants of Health (SDOH) needs. Serving as a patient advocate, this role manages chronic conditions through tailored care plans, health education, medication counseling, and follow-up monitoring. By collaborating with interdisciplinary teams and community partners, the Care Coordinator empowers diverse patient populations toward self-management to reduce health disparities and improve overall outcomes.

Requirements

Graduation from an accredited school or university as a Registered Nurse, or another bachelors or masters level degree with significant clinical experience.
Registered Nurse in the State of Hawaii. RN License is current, valid and in good standing.
Familiarity with common software programs, (i.e. Windows-based programs) an ability to quickly learn new systems.
Ability to communicate effectively with patients, community members, and staff members.
Proficient in computer skills: typing, navigating through the internet and emails.
OSHA training.
BCLS biannually

Nice To Haves

A minimum of five years of experience including chronic disease management is preferred

Responsibilities

Identify and Assess Target Populations: Collaborate with interdisciplinary teams and analyze data (EMR, ER/hospital reports, PRAPARE screenings) to identify high-utilizing, complex, and uncontrolled chronic disease patients requiring PCMH care coordination.
Develop Patient-Centered Care Plans: Conduct comprehensive assessments of patient health literacy, medications, and labs to build tailored care plans utilizing SMART goals that promote self-management.
Deliver Evidence-Based Disease Management: Implement specialized chronic disease protocols, including diabetes self-management support and the American Heart Association’s Self-Monitoring Blood Pressure (SMBP) program.
Coordinate Holistic Continuity of Care: Facilitate internal health transitions (Behavioral Health, Dental, Nutrition) and external community resource linkages to address Social Determinants of Health (SDOH) and manage post-discharge follow-ups.
Manage Quality & Program Compliance: Track clinical quality measures, maintain EMR documentation within 24–72 hours, and support quality initiatives to help maintain the clinic's PCMH Annual Recognition.
Other duties as assigned