RN Care Navigator: Transitions & Community Care

Andrews Institute; Pensacola (FL); Hybrid; USD 65,000 - 90,000; Full time

Job summary

The RN - Clinical Care Coordinator at Baptist Hospital in Pensacola, FL coordinates patient care across the continuum, emphasizing transitions, outpatient and post-acute care, and community resources. You will collaborate with physicians, care teams, patients, families, and resources to improve care transitions, reduce readmissions, and enhance patient engagement and satisfaction.

Florida RN licensure and 1 year in care coordination or chronic-disease management are preferred; this is a

Qualifications

• Registered Nurse licensed in Florida or compact state.
• 1 year experience in care coordination or transitional care management (preferred).
• Experience with chronic conditions (CHF, COPD, diabetes) (preferred).

Responsibilities

• Coordinate care across the continuum with patients, families, physicians, advanced practice providers, and community resources to ensure safe transitions.
• Identify high-risk patients and develop individualized care plans addressing clinical and social needs.
• Assess barriers to care and connect patients with resources for adherence, self-management, and access.
• Communicate with interdisciplinary teams regarding patient needs, care plans, transitions, and events.
• Evaluate problems and outcomes to meet patient and family needs and quality standards.
• Review discharge reports to plan post-discharge needs for high-risk patients.
• Coordinate with Baptist freestanding EDs for navigation, referrals, and follow-up care.
• Maintain accurate documentation in line with policies and standards.
• Maintain current licensure and competencies in care coordination and population health.

Skills

Care coordination

Patient communication

Collaboration

Clinical assessment

Education

Technical Diploma/Certificate Nursing

Associates Degree Nursing

Tools

EHR systems

Job description

The RN - Clinical Care Coordinator at Baptist Hospital in Pensacola, FL coordinates patient care across the continuum, emphasizing transitions, outpatient and post-acute care, and community resources. You will collaborate with physicians, care teams, patients, families, and resources to improve care transitions, reduce readmissions, and enhance patient engagement and satisfaction.

Florida RN licensure and 1 year in care coordination or chronic-disease management are preferred; this is a