JOB SUMMARY ** Ideal candidate to be located within an hour from a Family Health Center location. ** The RN Care Coordinator is responsible for coordinating, implementing, and evaluating comprehensive care plans for patients with complex medical and social needs. Working in collaboration with an interdisciplinary healthcare team, the RN Care Coordinator supports improved access to care, reduction in hospital utilization, and delivery of high-quality, patient-centered services. This role emphasizes holistic assessment, care coordination, patient education, and empowerment to promote wellness and independence across the continuum of care. ESSENTIAL JOB FUNCTIONS • Develops, implements, coordinates, and evaluates individualized healthcare plans in collaboration with interdisciplinary teams to improve access, reduce hospitalizations, and ensure quality care delivery. • Collaborates with providers and practice staff to identify appropriate patients for care management, utilizing established program criteria. • Performs comprehensive initial and periodic assessments, collecting relevant data on the patient’s health status and prioritizing patients based on intensity, need, and required follow-up. • Formulates and implements care management plans that address patient/family needs, resources, and goals; educates patients and families on care choices and supports informed decision-making. • Establishes mutually agreed-upon care plans with patients, families, and care teams that include clear, action-oriented self-management goals. • Evaluates the effectiveness of care plans, revising as needed to address evolving needs, goals, and barriers, monitors and documents patient progress. • Coordinates multidisciplinary care conferences to address patient progress, emerging issues, and shared team responsibilities. • Identifies and utilizes appropriate community resources to support patient/family needs; facilitates referrals as necessary. • Promotes patient self-management and engagement to achieve optimal wellness and independence through education and support. • Conducts post-discharge follow-up calls for high-risk patients recently hospitalized or treated in emergency departments to ensure safe and effective transitions of care. • Collaborates with providers, inpatient teams, payers, and health system administrators to coordinate transitions across care settings and optimize clinical and financial outcomes. • Maintains accurate, timely documentation in the electronic medical record (EMR) and ensures completeness of care management databases. • Manages a caseload of approximately 50–100 patients, meeting established productivity and quality standards. • Maintains professional boundaries and upholds confidentiality, ethics, and organizational values in all interactions. • Maintains strict adherence to scheduled work hours with regular and reliable attendance. • Performs other duties as assigned. EDUCATION AND EXPERIENCE • Associate’s degree in nursing. • Minimum of three years of recent clinical experience in a hospital or clinic setting working with adult patients. • Demonstrated experience providing patient interaction and support by telephone. • Proficient in the use of computers and electronic health record systems in a clinical setting. • Bachelor of Science in Nursing (BSN) preferred. • Bilingual in English and Spanish preferred. CERTIFICATIONS / LICENSES • Current State of Wisconsin Registered Nurse License. • Basic Life Support (BLS) certification at time of hire, or within three-months of employment. • Valid Wisconsin Driver’s License required with an acceptable motor vehicle record (MVR), per FHC guidelines. Equal Employment Opportunity