The RN - Clinical Care Coordinator – Continuum of Care is a registered nurse responsible for coordinating patient care across the continuum, with particular emphasis on outpatient, ambulatory, free standing emergency department, post-acute, and community-based settings. The Clinical Care Coordinator collaborates with physicians, advanced practice providers, care teams, patients, families, and community resources to improve care transitions, reduce avoidable utilization, address social determinants of health, improve quality outcomes, and support patient self-management.
Core deliverables include successful transitions of care, free standing emergency department care coordination, reduction of avoidable hospital utilization, improved patient engagement, reduced readmissions, closure of care gaps, population health outcomes, patient satisfaction, and connection to appropriate community resources. Responsibilities Collaborates with patients, families, physicians, advanced practice providers, free standing emergency department staff, ambulatory practices, post-acute providers, and community resources to coordinate care across the continuum and facilitate safe, efficient transitions between care settings and timely follow-up.
Identifies patients at increased risk for hospitalization, readmission, emergency department utilization, poor health outcomes, or unmet social needs; develops and implements individualized care plans to address clinical, psychosocial, and resource needs Assesses barriers to care, including social determinants of health, and connects patients with internal and external resources to support treatment adherence, self-management, access to care, and overall well-being.
Communicates and collaborates with interdisciplinary teams regarding patient needs, care plans, transitions, and significant clinical events to ensure coordinated delivery of services. Evaluates the identified problems, care provided, and patient’s responses are reassessed to meet patient and family needs and assure overall quality of care delivered. Evaluates daily inpatient discharge reports to prioritize post-discharge needs, including abnormal laboratory findings, pending diagnostic results, follow up appointment scheduling, and care coordination for high-risk readmission patients.
Identifies barriers to successful recovery and coordinates interventions to reduce avoidable readmissions and emergency department utilization. Serves upon request as a care coordination resource for Baptist freestanding emergency departments by assisting with patient navigation, community resource referrals, follow-up care arrangements, chronic disease management support, and appropriate disposition planning. Maintains accurate and timely documentation in accordance with organizational policies, regulatory requirements, and professional standards.
Maintains current clinical knowledge, licensure, certifications, and competencies relevant to care coordination, population health, and transitional care management. Minimum Education Technical Diploma/Certificate Nursing Required or Associates Degree Nursing Required Minimum Work Experience 1 year Experience in care coordination, case management, or transitional care management. Preferred 1 year Experience managing patients with chronic and complex medical conditions, including CHF, COPD, diabetes, and other high-risk populations.
Preferred 1 year Experience conducting post-discharge patient follow-up and care transition activities. Preferred Licenses and Certifications Registered Nurse Licensed State of Florida or compact state Upon Hire Required
Full time · Day shift · 40 hours per week