Role Overview: The RN Field Clinical Care Coordinator plays a vital role in an integrated care model by assessing members’ medical, behavioral, functional, cultural, and socioeconomic needs. They develop and manage personalized care plans, coordinate referrals to social services, and serve as the primary point of contact throughout the care continuum. The position involves engaging with members face-to-face or telephonically, collaborating with care teams and community resources to ensure timely, quality care.
Responsibilities include:
- Conducting comprehensive needs assessments
- Planning and implementing individualized care strategies
- Managing care plans and referrals
- Partnering with internal teams and external providers
- Communicating health information to stakeholders
Qualifications & Skills: Current unrestricted RN licensure in MA, 2+ years clinical experience, proficiency in MS Office, reliable internet and transportation, and ability to travel locally. Preferred qualifications include a Bachelor’s or Master’s in Nursing, CCM certification, community case management experience, bilingual skills, and familiarity with electronic health records.
Key Attributes: Flexibility, patience, adaptability, and ability to work in fast-paced environments, including navigating various terrains and working in both office and field settings.