RN Care Coordinator

Crouse Health; City of Syracuse (NY); On-site; USD 69,000 - 83,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Life insurance

FSA/HSA

Employee assistance program

PTO 15 days

Holidays 7

401(k) with match

Affiliation with Crouse Hospital

Job summary

Crouse Medical Practice in Syracuse, NY is seeking a qualified RN Care Coordinator – CCM to serve Medicare beneficiaries with two or more chronic conditions. You will act as a proactive patient advocate, educator, and care manager within a collaborative team-based model.

The role emphasizes early intervention, care coordination across primary and specialty services, and empowerment of patients to manage chronic conditions.

Qualifications

• Current RN licensure in New York State.
• Associate’s Degree in Nursing; BSN preferred.
• Strong interpersonal communication and motivational interviewing skills.
• Demonstrated understanding of chronic conditions, medication management, and preventative health.
• Experience in case management, population health, or care coordination preferred.
• Familiarity with EMR systems and Microsoft Office.
• Commitment to cultural humility and sensitivity to diverse populations.

Responsibilities

• Serve as the primary contact and trusted health advocate for an assigned caseload of Medicare patients with two or more chronic conditions.
• Build long-term rapport through monthly outreach calls and routine communication.
• Conduct thorough assessments of physical, emotional, social, and environmental needs.
• Develop and regularly update a comprehensive, patient-centered care plan with measurable goals and interventions, documented in the EMR.
• Promote self-management and health literacy through coaching, education, and collaborative goal setting.
• Coordinate internal and external services including primary care, specialty care, behavioral health, pharmacy, social services, and community resources.
• Prevent avoidable hospitalizations and ER visits through timely follow-up, medication review, and problem-solving interventions.
• Support transitions of care by ensuring communication, scheduling follow-ups, and medication reconciliation.
• Document all interactions, assessments, and updates per CMS billing requirements.
• Actively participate in team huddles, staff meetings, and improvement initiatives.
• Maintain productivity standards and contribute to department-wide billable goals.
• Assist in supporting new team members and sharing best practices.
• Enroll new patients into the CCM program and assess eligibility based on insurance, history, and risk-level.

Skills

Interpersonal communication

Motivational interviewing

Chronic condition knowledge

Medication management

Population health

Education

Associate’s Degree in Nursing

BSN preferred

Tools

EMR systems

Microsoft Office

Job description

Why Crouse Medical Practice?

At Crouse Medical Practice, our focus is on improving the lives of our patients. This focus is what drives us to recruit the best employees to support our patients. Our practice fosters an inclusive environment that prioritizes work-life balance, welcoming individuals from all backgrounds to join our close-knit work family.

Chronic Care Management 109

Syracuse , NY

Clinical

Full-Time, Days, 8:00am - 4:30pm

Req # 33032

Posted 09/17/2026

Here’s What We Offer

• Monday-Friday work week
• Supportive team environment
• Competitive starting rates based on experience
• Annual salary increases
• Opportunities for professional growth & stability within a fast-growing Medical Practice
• Longevity and consistency of management
• Perfect attendance award
• Tuition reimbursement program
• Employee referral program
• Affiliation with Crouse Hospital

Other benefits include:

Generous Health/Dental/Vision & Life insurance, Flexible spending account or Health savings account – available first of the month following your date of hire, Employee assistance program,15 days of paid time-off within first year of employment, 7 paid holidays annually, and a 401k with 4% employer match.

Position Description

The RN Care Coordinator – CCM serves as a proactive patient advocate, educator, and care manager for Medicare beneficiaries enrolled in Chronic Care Management services. This role is grounded in a team-based, patient-centered approach that prioritizes relationship-building, early intervention, and coordination across the care continuum. The RN uses clinical knowledge and care coordination skills to empower patients to manage chronic conditions effectively, reduce unnecessary utilization, and improve quality of life.

Responsibilities

• Serve as the primary point of contact and trusted health advocate for an assigned caseload of Medicare patients with two or more chronic conditions.
• Build long-term rapport through monthly outreach calls and routine communication
• Conduct thorough assessments of physical, emotional, social, and environmental needs.
• Develop and regularly update a comprehensive, patient-centered care plan with measurable goals and interventions, documented in the EMR.
• Promote self-management and health literacy through coaching, education, and collaborative goal setting.
• Coordinate internal and external services including primary care, specialty care, behavioral health, pharmacy, social services, and community resources.
• Prevent avoidable hospitalizations and ER visits through timely follow-up, medication review, and problem-solving interventions.
• Support transitions of care by ensuring communication, scheduling follow-ups, and medication reconciliation.
• Document all interactions, assessments, and updates per CMS billing requirements.
• Actively participate in team huddles, staff meetings, and improvement initiatives.
• Maintain productivity standards and contribute to department-wide billable goals.
• Assist in supporting new team members and sharing best practices.
• Enroll new patients into the CCM program and assess eligibility based on insurance, history, and risk-level.

Minimum Qualifications

• Current RN licensure in New York State.
• Associate’s Degree in Nursing; BSN preferred.
• Strong interpersonal communication and motivational interviewing skills.
• Demonstrated understanding of chronic conditions, medication management, and preventative health.
• Experience in case management, population health, or care coordination preferred.
• Familiarity with EMR systems and Microsoft Office.
• Commitment to cultural humility and sensitivity to diverse populations.

Pay Range: $69,000.00 - $83,000.00

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