Rural Health Care Navigator

Sun River Health; City of Poughkeepsie (NY); Hybrid; USD 78,000 - 101,000; Full time

Job summary

Sun River Health in New York seeks a Clinical Coordinator Rural Health to support coordination and delivery of timely, cost-effective care for patients in rural communities. This role works across transitions of care, high-risk care management, and care coordination to reduce avoidable ED visits, hospitalizations, readmissions, and gaps in care.

The Clinical Coordinator leads proactive, team-based care for patients at high risk for readmissions, ED use, or fragmented care.

Qualifications

• Current, unencumbered LPN license in New York.
• Proficiency with electronic health records and standard office productivity tools; comfort with telehealth.
• Strong clinical assessment and prioritization skills in a remote, high-volume environment.
• Excellent verbal and written communication; ability to build rapport with patients and cross-site teams.
• Cultural humility and experience serving diverse, underserved, and rural communities preferred.
• Bilingual (English/Spanish) preferred.
• CPR/BLS certification current.

Responsibilities

• Identify patients in Dutchess County with high needs and/or high utilization.
• Develop and support partnerships with hospital discharge planning for TOC coordination.
• Engage patients with high needs/high utilization to appropriate levels of care and increase primary care utilization.
• Develop and utilize protocols for complex care including CHF, DM, CVD, SUD and BH.
• Coordinate longitudinal care across primary care, specialty, hospital, home-health, and community services, with a rural Sun River Health focus.
• Conduct structured outreach after ED visits and hospital discharges to assess symptoms, medication access, and follow-up needs.

Skills

LPN license

EHR proficiency

Telehealth

Communication

Cultural humility

Bilingual

CPR/BLS

Job description

Sun River Health in New York seeks a Clinical Coordinator Rural Health to support coordination and delivery of timely, cost-effective care for patients in rural communities. This role works across transitions of care, high-risk care management, and care coordination to reduce avoidable ED visits, hospitalizations, readmissions, and gaps in care.

The Clinical Coordinator leads proactive, team-based care for patients at high risk for readmissions, ED use, or fragmented care.