RN Care Coordinator

Southwest Care Center; Santa Fe (NM); On-site; USD 65,000 - 85,000; Full time

Job summary

Southwest Care Center seeks a Registered Nurse Care Coordinator to join our Santa Fe, NM clinics. You will coordinate care across primary and specialty services, manage transitions from hospital to home, and advocate for patient needs within a diverse community.

The role emphasizes patient education, medication reconciliation, and collaboration with the healthcare team to improve outcomes and access to community resources.

Qualifications

• Must hold active RN license.
• Experience in hospital-to-home transitions is preferred.
• Strong communication and patient education skills required.

Responsibilities

• Identify and follow up on hospital and ED admissions and discharges.
• Oversee care transitions and coordinate post-discharge follow up with patients.
• Initiate patients' medication reconciliation.
• Link patients to community resources and social support.
• Educate patients and families on disease management and self-care.

Skills

Care coordination

Nursing assessment

Patient advocacy

Interdisciplinary teamwork

Education

RN license

Job description

Do you believe everyone is entitled to quality healthcare? Do you desire to serve the underserved in our community? Southwest Care Center (SCC) is a non‑profit healthcare organization who has been providing exceptional healthcare to people within our community for over 25 years. We provide services, including medical, behavioral healthcare, and community outreach, with health centers located in Santa Fe, Albuquerque, Farmington, and Roswell, NM. Southwest Care Center is an FQHC-LAL. Southwest Care Center is currently seeking a Registered Nurse Care Coordinator within our Santa Fe, NM clinics where we offer both Primary and Specialty Care Services at 3 locations. You will become a part of a dynamic group of healthcare professionals who strive each day to provide outstanding care within the diverse community of Santa Fe.

Southwest Care Center offers a full benefits package including medical, dental, vision, life, long term and short-term disability and a 401k retirement fund. Additionally, CME reimbursement is available Participate in the identification of high risk/high acuity patients.

Identify and follow up on hospital and emergency department admissions and discharges.

Oversee care transitions (hospital to home, hospital to rehabilitation center/nursing facility) and coordinate follow up with patient.

Initiate patients' medication reconciliation.

Oversee patients' linkages to community resources and social support.

Closely coordinated and facilitate patients' care with primary care providers, behavioral health specialist and outside providers.

Acts as a patient advocate protecting privacy and confidentiality.

Maintain a comprehensive working knowledge of community resources, payer requirements, and network services for target population.

Promote patients’ independence by establishing patient care goals; teaching and counseling patient, friends, and family and reinforcing their understanding of disease, medications, and self‑care skills.

Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem‑solving methods.

Models and supports development of Medical Assistants.

Demonstrates prioritization, critical‑thinking and decision‑making skills.

Offers insight and direction in dealing with clinical situations and responds accordingly.

Embraces change that improves results and assists others through the change process.

Acts as a team member and which provides efficient patient care practices, collaborates with the health care team to assure a team approach.

Conduct nurse visits to ensure patient care plan is followed.

Communicates effectively in a timely manner.

Maintains good working relationships with the health care team in solving problems/issues in delivery of services.

Provides constructive feedback; resolves conflicts and issues in a timely manner and refers issues as appropriate.

Maintains effective lines of communication with staff.

Communicates significant clinical issues; keeps leadership apprised of workflow issues and supervisory activities.

Contributes to developing and attaining long‑range objectives including, but not limited to: financial goals, operations improvement, quality improvement, resource utilization and clinical practice enhancements.

Represents clinic on inter‑disciplinary committees/work groups.

Identifies key performance indicators for self and team members and develops methods for reaching established goals and measurement of each.

Participates in developmental and educational programs.

Living & Working in New Mexico: The Land of Enchantment offers residents a way of life that you won’t find anywhere else in the United States. Our clinic locations are in Santa Fe and Albuquerque, NM. Each with its own unique vibe and both offering all the perks you get when you call New Mexico Home. Rich cultural and historical diversity. 310 days of sunshine, combined with a mild, dry climate and four distinct seasons! You’ll forget what humidity is when you live here. Unlimited year‑round outdoor opportunities including hiking, rock‑climbing, rafting, motorized sports, and even skiing. Yes, we have really big ski mountains in and around the deserts of New Mexico! Diverse and inclusive communities with amazingly kind people from all walks of life. Gorgeous landscapes that include desert and majestic mountains. New Mexico has to be to be seen to believe. Continuous festivals, concerts, and events including the internationally known Balloon Fiesta of Albuquerque. International airport providing low-cost, quick access in-country and out. Big city amenities found in Albuquerque with easy access from Santa Fe (50 min). Many of our employees commute between these cities. Both cities are connected by the NM rail system for those looking for a relaxing commute with a breath‑taking view. Great schools and family friendly communities. And let’s not forget about New Mexican cuisine—it is some of the best food in the country. Will you have red or green?

Southwest Care Center is an equal opportunity employer. We offer equal employment opportunities to employees and applicants without regard to race, color, religion, sex, age, national origin, disability status, protected veteran status, sexual orientation, gender identity, or any other characteristic protected by federal or state law.

Job Details: Location: NM Santa Fe - Harkle Worker Type: Employee Regular Scheduled Weekly Hours: 40