Hometown Health Center | ME, United States

Posted Date 11/18/2022

Position Title:

RN Care Coordinator



Reports To:

Practice Manager



FLSA Status:


Last Revised/Approved:

January 2022


The RN Care Coordinator facilitates a smooth transition of care for each patient from the hospital back to the Primary Care Physician; monitors high risk/high utilizers of care as well as under-utilizers of care; monitors population health with regard to disease management and helps patients set realistic treatment goals; facilitates preventative health measures and educates patients regarding preventative health; assists the Quality Improvement Committee in assessing any risk management issues involving a patient; involved in multiple outreach events throughout the year.


  1. Assists all patients through the healthcare system by acting as a patient advocate.
  2. Participates in daily care team huddle to assist in pre-visit planning and identify patients who may benefit from an integrated visit with care management/coordination services.
  3. Coordinates continuity of patient care with patients and families following hospital admission, discharge, and emergency visits.
  4. Manages Population Health and Disease.
  5. Facilitates health and disease patient education, including leading group office visits.
  6. Supports patient self-management of disease and behavior modification interventions.
  7. Monitors high utilizers of services.
  8. Addresses Preventative health within the practice.
  9. Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
  10. Assists population health medical assistant with data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient Centered Medical Home initiatives as appropriate.
  11. Performs job utilizing the policy, protocols and standing orders for delivering care coordination.
  12. Documents patient records using an Electronic Health Record.
  13. Participates in Patient Centered Medical Home team meetings and quality improvement initiatives.
  14. Assists in improving the policy/procedures for the Care Coordination program.
  15. Assists in improving the policy/procedures for the Clinical staff including MA’s and Providers.


  1. Performs other duties as assigned.


  1. Good organizational skills to handle multiple priorities while remaining professional and calm.
  2. Ability to work with many diverse people.
  3. Effective telephone skills.
  4. Strong level of confidentiality due to the sensitivity of materials and information handled.
  5. Must able to make suggestions on workflow or system efficiency and effectiveness.
  6. Ability to work independently and be self directed and flexible.
  7. Ability to prioritize.
  8. Ability to perform functions with minimal supervision.
  9. Ability to work at a high volume level of accuracy.


  1. Be committed to the mission of the Hometown Health Center.
  2. Behave in a professional manner and consistently demonstrate and promote the values of respect, honesty, and dignity for the patient, families, and all members of the healthcare team.
  3. Committed to the constant pursuit of excellence and teamwork in improving the care of the patient and families of Hometown Health Center and the Patient Centered Medical Home Neighborhood.
  4. Be punctual for scheduled work and use time appropriately.
  5. Perform duties in a conscientious, cooperative manner.
  6. Perform required amount of work in a timely fashion with a minimum of errors.
  7. Be neat and maintain a professional appearance.
  8. Maintain confidentiality and protect the Practice by abiding by laws and principles related to confidentiality; keep information concerning Practice Operations, patients and employees confidential.
  9. This position requires compliance with Health Center’s compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the Pediatrician’s regular performance evaluation.
  10. Adhere to Hometown Health Center’s employee immunization policy.


The physical requirements described here are representative of those that must be met by the Incumbent to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand or sit for prolonged periods of time, and talk and hear. The employee is occasionally required to walk and use hands to operate a standard computer keyboard. The employee may occasionally lift and/or move up to 10 pounds. Vision requirements include: close vision, distance vision, depth perception, and the ability to adjust focus.


The work environment characteristics described here are representative of those the incumbent encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work is performed in a busy medical office environment with many interruptions. Noise level is moderate. Very active, fast paced position with short deadlines. At times, must interact with irate patients and remain calm and professional. High risk exposure to blood borne pathogens and chemical hazards.


  1. Minimum of 3 year of professional level medical experience; experience in care coordination preferred.
  2. Experience working with an electronic medical records required.
  3. Ability to work collaboratively with people of diverse cultures and lifestyles.
  4. Ability to communicate effectively with providers and medical staff.
  5. Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
  6. Ability to be self-motivating and work independently.
  7. Computer literacy.
  8. Excellent written and oral communication skills.
  9. Problem solving skills.


The following education requirements are considered essential:

  1. RN required.
  2. Proficiency in medication knowledge and basic medical terminology knowledge.
  3. Demonstrated knowledge of both generic and brand name medications.
  4. Basic understanding of medical tests and requirements for test as to provide the patients with appropriate information.

** All requirements and skills are considered to be essential, unless otherwise indicated. **

External and internal applicants, as well as position incumbents who become disabled as defined under the Americans With Disabilities Act, must be able to perform the essential job functions (as listed) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis.

The job description does not constitute an employment agreement between the employer and the employee and is subject to change by the employer as the needs of the employer and requirements of the job change.


I have received a copy of my job description and can perform the essential functions of the job, with or without reasonable accommodation.

_________________________________ _____ / _____ / ________

Employee’s Signature Date


Print Name

_________________________________ _____ / _____ / _________

Supervisor’s Signature

Hometown Health Center is an equal opportunity provider and employer and is an FTCA deemed organization.


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