RN Embedded Care Coordinator - Foundation Collaborative Care - Full Time - Foundation Medical Partners

SolutionHealth • Nashua, NH

1d • Onsite

About The Position

The RN Embedded Care Coordinator plays a critical role within a primary care practice, focusing on managing care for complex and high-risk patients. This position partners closely with providers and care teams to deliver proactive, coordinated, and patient-centered care that improves outcomes and supports patients in managing their health.

Requirements

• Associate’s Degree in Nursing (ASN) from an accredited program
• Active Registered Nurse (RN) license in the state of New Hampshire
• Current BLS/CPR certification
• 2+ years of clinical nursing experience in a relevant specialty

Nice To Haves

• Bachelor of Science in Nursing (BSN) or enrollment in a BSN program
• Experience in ambulatory care, case management, population health, or public health
• Certification in Ambulatory Care Nursing (RN-BC), Care Coordination (CCTM), or similar
• Strong clinical knowledge, particularly in chronic disease management
• Excellent communication, coaching, and patient education skills
• Ability to manage a dynamic caseload of approximately 150 patients
• High emotional intelligence, organization, and adaptability
• Comfort with EMR systems and data-driven care tools

Responsibilities

• Manage a panel of complex patients, developing individualized, longitudinal care plans in collaboration with an interdisciplinary team
• Provide chronic disease education and self-management support (e.g., diabetes, COPD, CHF, asthma)
• Coordinate care across settings, including hospital discharges, specialty referrals, and pre-visit planning
• Conduct patient assessments and interventions in-person, via phone triage, and through telehealth
• Proactively manage transitions of care to reduce readmissions and improve continuity
• Utilize population health tools and EMR systems to identify and manage patients in need of care coordination
• Serve as a liaison between patients, providers, and community resources to ensure seamless care delivery
• Support quality improvement initiatives focused on patient safety, outcomes, and access to care

Benefits

• Health, dental, prescription, and vision coverage for full-time & part-time employees
• Short-term and long-term disability, life, and pet insurance
• Tuition reimbursement
• Nursing Student Loan Paydown Program
• 403(b) retirement savings plan with company match
• Continuous earned time accrual

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree