Patient Care Coordinator - (RN)

About the role

Empowering communities through accessible, inclusive, and compassionate care, this is the work we do every day.

At Jane Pauley Community Health Center, every role is connected to something bigger. As a Federally Qualified Health Center (FQHC), we deliver integrated, whole-person care to individuals and families across Indiana, regardless of income or insurance status.

Our teams work at the intersection of clinical excellence and community impact, supporting underserved populations while building a culture rooted in collaboration, respect, and growth. Here, you are not just joining a workplace, you are becoming part of a mission that truly matters.

Summary

The RN Patient Care Coordinator is an essential member of the practice care team at The Jane Pauley Community Health Center (JPCHC). Working under the direction of the Regional Nurse Administrator, the RN Patient Care Coordinator supports health promotion, disease prevention, patient self-management, patient education, nursing care planning, and coordination of care. This is a hybrid remote position.

The nurse must be able to report for in-office work as requested or as needed by the organization, with remote work flexibility determined by the needs of the organization and the nurse. Specific work arrangements are outlined in the organization's remote work agreement.

Essential Duties and Responsibilities

Patient Advocacy and Care Coordination

• Serves as a patient advocate, helping patients navigate the healthcare system.
• Provides patient education tailored to the needs of the patient using evidence-based practices and approved resources.
• Empowers patients to be actively engaged in their healthcare and supports patient self-management of disease using behavior modification interventions.
• Coordinates continuity of care between primary care and specialty providers.
• Conducts telephonic outreach to patients with recent hospitalizations or emergency department visits to ensure continuity of care, reduce re-admissions, and prevent avoidable hospital stays.
• Conducts telephone triage within scope of licensure using age-appropriate clinical assessment and approved protocols.
• Partners with providers, clinical support staff, and pharmacies to manage refill requests per established protocols and resolve prior authorization barriers, keeping patients on track with their treatment plans.
• Maintains accurate, complete, and timely EMR documentation of patient encounters, calls, and outreach attempts in accordance with the nursing process and organizational standards.

Quality Improvement

• Partners with patients, families, and interdisciplinary providers to manage an assigned high-risk population, reinforcing the provider's plan of care and resolving barriers to adherence in order to achieve optimal health outcomes and improve performance on quality measures.
• Conducts proactive outreach to patients to ensure completion of recommended preventive screenings, supporting early detection, disease prevention, and strong performance on quality measures.
• Participates in clinical quality improvement initiatives and committees.

Precepting/Mentorship

• Participates in precepting newly hired nurses and nursing students as assigned.
• Serve as a clinical resource and mentor to nursing and clinical support staff, by sharing expertise, answering questions, and modeling best practices.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

• Must demonstrate professionalism, initiative, and a strong commitment to patient safety, teamwork, patient experience, and quality improvement.
• Requires critical thinking skills, sound clinical decision making, and the ability to work with minimal supervision.
• Must be able to manage competing priorities and respond to urgent patient situations in a fast-paced setting.
• Must possess the ability to assess patients without face-to-face interaction
• Must maintain patient confidentiality and comply with HIPAA and organizational privacy and security policies.
• Must demonstrate working knowledge of the Indiana Nurse Practice Act and practice within the scope of RN licensure.

Education and/or Experience

Required

• Graduation from accredited Nursing Program - ADN required; BSN preferred
• Current, unrestricted Registered Nurse license in the State of Indiana or a valid multistate (compact) license recognized in Indiana.
• Current Basic Life Support (BLS) certification through AHA
• Minimum of 1 year nursing experience in triage, acute care, ambulatory care, case management, or insurance setting.

Preferred

• At least two years of experience in chronic disease management, case management, utilization management, or adult acute care.
• Experience with telephone triage and transitions of care management
• Experience in, or working knowledge of the Patient-Centered Medical Home model
• Experience with quality measures such as Healthcare Effectiveness Data and Information Set (HEDIS) and Uniform Data System (UDS)
• Certification in ambulatory care nursing or case management

Computer Skills

To perform this job successfully, an individual must be proficient with electronic medical record (EMR) systems, including documentation, order management, and patient messaging. Working knowledge of Microsoft Office (especially Word and Excel), telephone and virtual communication platforms, and other applications is also required.

• Regularly required to sit for extended periods, use hands to finger, handle, or feel, reach with hands and arms, and talk or hear.
• Regularly uses a telephone headset and computer for extended periods.
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.
• Occasional on-site work may require walking, standing, or lifting up to 25 pounds
• The noise level in the work environment is usually moderate.
• Remote work must be performed in a private, HIPAA-secure space where patient information and phone conversations cannot be seen or overheard by others, in accordance with organizational privacy and security policies.
• Remote work requires a reliable high-speed internet connection and a secure network.