RN Care Coordinator: Complex, Coordinated Care

Southern New Hampshire Health; Manchester (NH); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Health coverage

Dental coverage

Vision coverage

Disability insurance

Life insurance

Tuition reimbursement

403(b) retirement plan

Competitive pay

Job summary

Elliot Health System is seeking a Nurse Care Coordinator to organize team-based care planning for high-risk patients with complex needs, coordinating with patients, families, and community resources to ensure timely, cost-effective, high-quality care.

The role focuses on care management across the continuum, including short-term transitions and ongoing care planning, with an emphasis on patient and family-centered approaches and health coaching to improve outcomes and engagement.

Qualifications

• 5+ years nursing experience in acute, skilled nursing, community health and/or ambulatory setting is required.
• 3+ years’ experience in care coordination or case management in acute, skilled nursing, community health, and/or ambulatory setting preferred.
• Current nursing licensure in the state of New Hampshire required; Massachusetts licensure in addition to NH preferred.
• Specialty certifications such as ambulatory nursing, CCM, CCTM, Guided care, CHCQM preferred.

Responsibilities

• Manages a panel of active patients requiring complex care management and coordination support.
• Collaborates with the multidisciplinary team, including patients and their family, to design and implement holistic care plans.
• Assesses patient and family health and social needs and health literacy to resolve needs.
• Promotes patient engagement in self-care management and motivational interviewing.
• Provides chronic disease self-management education for patients enrolled in care coordination programs.
• Monitors adherence to plan of care and progress toward mutual goals; facilitates changes and creates action plans.
• Addresses barriers to goals through health coaching, access to community resources, and supports.
• Creates processes for determining and requesting levels of care coordination over time.
• Facilitates access to appropriate medical and community providers.

Skills

Care coordination

Nursing

Health coaching

Patient education

Education

BSN or higher in nursing

Job description

Elliot Health System is seeking a Nurse Care Coordinator to organize team-based care planning for high-risk patients with complex needs, coordinating with patients, families, and community resources to ensure timely, cost-effective, high-quality care.

The role focuses on care management across the continuum, including short-term transitions and ongoing care planning, with an emphasis on patient and family-centered approaches and health coaching to improve outcomes and engagement.