Remote RN Care Coordinator - Primary Care

PATH (People Assisting The Homeless) (Old); Bangor (ME); On-site; USD 108,886,000 - 120,347,000; Full time

Job summary

PATH (People Assisting The Homeless) seeks a Registered Nurse (RN) Care Coordinator – Primary Care to support patients after hospital, skilled nursing facility, and ED visits, with focus on transitional and chronic care management. Fully remote; candidates must reside in Maine.

You will provide care planning, medication-safety support, and proactive outreach, coordinating with primary care teams, pharmacists, specialists, and community resources.

Qualifications

• Registered Nurse with active state licensure; BSN preferred.
• Minimum of 3 years’ experience in primary care, case management, or population health settings.
• Skilled in telephonic and virtual patient communication, clinical assessment, and coordination across settings.
• Proficient in using EHRs, and population health analytics tools.
• Familiarity with CMS Care Coordination Services standards and guidelines preferred.
• Ability to collaborate effectively communicate across multidisciplinary and multisite teams.

Responsibilities

• Provide timely outreach to patients following discharge to support transitions.
• Complete post-discharge clinical assessments, medication reconciliation, patient and caregiver education, and coordination of timely follow-up appointments.
• Identify and address barriers to recovery and ongoing care, including medication access, transportation, health literacy, behavioral health, social needs, and connection to community resources.
• Provide ongoing chronic care management for patients with complex or chronic conditions, including care planning, disease education, symptom monitoring, goal setting, and self-management support.
• Work closely with primary-care providers, care teams, pharmacists, specialists, hospitals, home health agencies, and community partners to ensure coordinated, patient-centered care.
• Recognize changes in patient condition, respond to urgent clinical needs, and facilitate appropriate follow-up or escalation of care.
• Document care-management services, patient outreach, clinical assessments, education, and coordination activities in the electronic health record in accordance with organizational, ACO, payer, and CMS requirements.
• Engage in network quality initiatives aimed at reducing readmissions, improving medication adherence, and enhancing patient outcomes.
• Use data analytics to identify at-risk patients and develop targeted outreach strategies.
• Participate in cross-functional meetings to drive operational improvements.
• Participate in the implementation of network-wide controlled substance monitoring protocols, collaborating with providers to ensure compliance and safety.
• Review patient histories for risk, support utilization of prescription drug monitoring programs, and provide education on safe use, storage, and disposal.

Skills

Registered Nurse (RN)

Telephonic communication

Virtual communication

EHR literacy

Population health analytics

Team collaboration

Education

BSN preferred

RN license active

Tools

EHR systems

Population health analytics tools

Job description

PATH (People Assisting The Homeless) seeks a Registered Nurse (RN) Care Coordinator – Primary Care to support patients after hospital, skilled nursing facility, and ED visits, with focus on transitional and chronic care management. Fully remote; candidates must reside in Maine.

You will provide care planning, medication-safety support, and proactive outreach, coordinating with primary care teams, pharmacists, specialists, and community resources.