Job Title: Care Coordinator Registered Nurse
Department: Neurology                   
Location: St. Lawrence Medical Campus, Canton, NY                           
Hours Per Week: 37.5 scheduled weekly hours
Schedule:  8-hour days, 8 am - 4pm                                    

SUMMARY: The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach. Facilitates “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered that address. Acts as a liaison between patients and the healthcare system. Ensures that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Coordination of patient-care services to help reduce costs by reducing duplication of services.

RESPONSIBILITIES:

Care Coordination

• Assess patients and develop evidence-based, individualized care plans.
• Coordinate with physicians, care teams, and community resources to ensure continuity of care.
• Educate patients and families on wellness, disease processes, medications, and lifestyle needs in a way suited to their learning abilities.
• Serve as the central contact and advocate to promote timely, appropriate care while reducing ER visits and hospital readmissions.
• Track, evaluate, and adjust care plans based on patient outcomes and barriers.

Care Delivery

• Provide safe, effective direct and indirect nursing care, including medication reconciliation and adjustments under physician guidelines.
• Perform RN-led Annual Wellness Visits and pre-visit planning.
• Triage patient calls, manage follow-up care, and communicate test results.
• Lead daily/weekly huddles with care teams to prepare for patient needs.

Quality & Regulatory

• Actively participate in performance and quality improvement initiatives.
• Ensure compliance with regulatory standards (DNV, hospital policies, and protocols).
• Identify and resolve clinical process issues to improve efficiency and outcomes.

People

• Mentor and support staff, serving as a resource within the clinic and hospital.
• Provide education to patients, caregivers, and staff while maintaining excellent communication in every encounter.

REQUIRED QUALIFICATIONS:

• Completion of an accredited Registered Nurse training program. BSN preferred.
• Current, unrestricted New York State registered professional nursing license
• Certification through the American Academy of Ambulatory Care Nursing in Care Coordination and Care Transitions required within 18 months of employment required.
• Chronic Disease Self-Management Certification required within 12 months of employment.
• Willingness to obtain ongoing and up to date population specific education
   

PREFERRED QUALIFICATIONS:

• 3-5 years’ experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
• Experience with Patient-Centered-Medical Home desirable.
• Experience with health IT systems and reports is desirable
• Local knowledge about and connections to community health care and social welfare resources is desirable             

• Ability to speak a relevant second language is desirable

EDUCATION:

LICENSES / CERTIFICATIONS: 

PHYSICAL REQUIREMENTS:

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.