Care Coordination Nurse – RN

Website Sawtooth Mountain Clinic

Together Through Life


The Care Coordination RN collaborates with primary care physicians, clinic staff and other Health Care Home team members to identify needs, provide education, and coordinate plans of care for identified patients. The care coordinator assists patients to achieve health goals and improved health care outcomes. The Care Coordinator is also an advocate for patients and, depending on patient need, may link patients with health and community resources that provide a range of services, promote self-management, improve health and reduce disparity.

Functions and Responsibilities:

1. Assess the Health Status of Patients:

a. Reviews SMC’s Chronic Disease Registry monthly reports to identify patients who qualify for Enhanced Care Coordination Services (ECC) and consults with medical provider. 

b. Plans, coordinates and provides patient-specific health education based on the chronic or associated conditions identified.

2. Develop and Maintain a Care Plan:

a. Works with the ECC patient, providers, and HCH Care Team members to develop and maintain an individualized clinical Care Plan for the patient if necessary

b. Collaborates with the provider and HCH Care Team to ensure Care Plan data is up-to-date and complete

c. Assists patients with the identification, selection, monitoring and documentation of self-management goals

d. Follows up with the patient to ensure the patient’s responsibilities are being followed and met. Monitors the patient’s progress toward goal achievement and modifies as needed

e. Schedules follow-up appointments or makes phone contact to ensure the patient is receiving needed services, that outcomes are improving, and to determine if progress is being made towards defined goals

3. Care Management:

a. Follows the prescribed care coordination workflow to comply with HCH certification requirements

b. Interacts and coordinates care with team members, providers, and coordinates appropriate referrals to specialists, and community resources to ensure comprehensive care for the patient

c. Serves as an advocate for the patient to understand needs (i.e. shelter, transportation, child care, safety) and arrange or coordinate applicable services

d. Collaborates with the nursing staff for pre-visit planning

e. Conducts regular, periodic care plan review with the patient and/or family. Arranges for interpreter services if needed f. Reviews care coordination patient’s records to determine when patients should be seen by their primary care provider for any one or more of their applicable chronic conditions and works with the patient to schedule an appointment

g. Notifies the primary care provider if patients decline or choose to leave the program. Keeps the provider informed on care coordination progress via EHR documentation

h. Discusses end-of-life situations, health care directives, and coordinates with the HCH team members

i. Identifies and/or updates the patient’s primary care provider (PCP) in the EHR

j. Discusses external care plans that other providers or services may have developed, incorporates that information into the care plan, and works with the patient to coordinate any supplemental or overlapping services

3. Other Duties:

k. All RNs at SMC are expected to train and maintain basic competency in SMC Triage protocols Job


a. Current Minnesota Nursing License

b. Bachelor of Nursing from an accredited school preferred

c. 2+ years experience in a health care setting, preferably primary care

d. Experience working with underserved and at-risk populations preferred

e. Ability to work both independently and collaboratively as an effective member of a health care team

f. Proven strong interpersonal skills

g. Ability to work comfortably at a computer for long periods of time

Salary: Commensurate with educational background and experience

Benefits: Excellent health and dental insurance, generous PTO, paid holidays, employer-funded 401k, Life Insurance, Disability Insurance.

Sawtooth Mountain Clinic is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, ancestry, age, physical or mental disability, sex, sexual orientation, gender identity/expression, pregnancy, veteran status, marital status, creed, status with regard to public assistance, genetic status or any other status protected by federal, state or local law.

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