Outpatient RN Care Coordinator — Transitional Care

Hunterdon Healthcare Partners; Flemington (NJ); On-site; USD 70,000 - 75,000; Full time

Job summary

Hunterdon Healthcare Partners is seeking an RN Care Coordinator to support high-risk outpatient populations, coordinating care across primary and specialty services to ensure safe transitions of care.

The role emphasizes engagement with hospitals, subacute facilities, and home health teams, using EMR and pursuing CMS-compliant Transition Care Management visits. Strong communication and collaboration are essential.

Qualifications

• BSN or RN with appropriate experience and CCM certification preferred.
• Minimum three years of acute, hospital-based direct patient care.
• Preferred five years of acute care with care coordination experience.
• Current NJ RN licensure.
• Strong verbal and written communication; ability to collaborate.

Responsibilities

• Provide outreach to identified patients, addressing social determinants of health, barriers to care, education on disease state and medications, coordinating care needs with primary care, specialty care and ancillary services.
• Develop constructive relationships with hospitals' admission offices, case managers, discharge planners, and ED contacts.
• Develop systems and processes to engage entities in care management and ensure post-discharge needs are met.
• Monitor coordination with home care agencies, specialists, or other resources.
• Ensure Transition Care Management visits are completed within CMS guidelines and facilitate follow-up visits with appropriate specialists.
• Educate patients and caregivers about new diagnoses, medications, and discharge instructions.
• Monitor that home care, hospice, and other ancillary services are in place.
• Utilize EMR to communicate with interdisciplinary teams.
• Assist with review of internal/payor reports to target populations and close gaps in care.
• Facilitate transportation services per policy.
• Attend scheduled or ad-hoc meetings or committees as requested.

Skills

Communication skills

Care coordination

Team collaboration

RN licensure

Education

RN with BSN

Tools

EMR

Job description

Hunterdon Healthcare Partners is seeking an RN Care Coordinator to support high-risk outpatient populations, coordinating care across primary and specialty services to ensure safe transitions of care.

The role emphasizes engagement with hospitals, subacute facilities, and home health teams, using EMR and pursuing CMS-compliant Transition Care Management visits. Strong communication and collaboration are essential.