RN Care Coordination & Prevention Specialist

Oak Orchard Health; New York (NY); On-site; USD 75,000 - 105,000; Full time

Job summary

Oak Orchard Health is seeking a Registered Nurse to lead a team-based approach, coordinating care for high-risk patients in a primary care setting. The RN will advocate, coach and educate patients at risk for hospital admissions or ER visits, and collaborate with the health care team to manage chronic conditions and prevention programs.

The role emphasizes care coordination, documentation, and patient education across locations, with flexible scheduling including some evenings or weekends as

Qualifications

• Graduate of an approved school of nursing with RN license to practice in NYS.
• 2-3 years’ experience in Primary Care, inpatient or outpatient Internal Medicine/Family Medicine, Public Health, Case Management, or related field preferred.
• Current certification in Basic Life Support for Healthcare Providers or equivalent.

Responsibilities

• Identify high-risk patients and establish relationships to enable effective intervention and support.
• Identify barriers to care and implement care plans to provide self-management support.
• Facilitate transition of care with comprehensive follow-up after discharge; provide discharge instructions and med questions.
• Promote population health and collaborate with outside agencies for best outcomes.
• Triage incoming calls and walk-in patients; follow up on ED/UC visits.
• Assist in population health efforts focusing on preventative care and chronic condition management.

Skills

Communication

Care coordination

Team collaboration

EHR proficiency

Bilingual (optional)

Education

RN license NYS

Tools

EHR

Microsoft Office

Job description

Oak Orchard Health is seeking a Registered Nurse to lead a team-based approach, coordinating care for high-risk patients in a primary care setting. The RN will advocate, coach and educate patients at risk for hospital admissions or ER visits, and collaborate with the health care team to manage chronic conditions and prevention programs.

The role emphasizes care coordination, documentation, and patient education across locations, with flexible scheduling including some evenings or weekends as