Care Coordinator - RN or LPN

Southwest Virginia Community Health Systems, Inc. (SVCHS) is seeking an experienced and compassionate Care Coordinator (RN or LPN) to join our multidisciplinary primary care team. This position coordinates services for high-risk patients, individuals with chronic illnesses, and patients managing multiple health conditions.

Working within a Patient-Centered Medical Home (PCMH) environment, the Care Coordinator partners with patients, families, healthcare providers, hospitals, specialists, health plans, and community organizations to improve continuity of care. The position plays an important role in reducing avoidable hospital admissions and emergency department visits, addressing barriers to care, and improving health outcomes.

Compensation and Benefits

Pay Range (based on licensure, skills, and experience): $20.00 - $26.00 per hour

Health, dental, and vision coverage

Group Term Life insurance

Voluntary Life Insurance

Voluntary Accident, Hospital Indemnity, Critical Illness, Short Term Disability, Long Term Disability

403(b) Retirement Plan with Employer Contribution

Paid Time Off

Key Responsibilities

1. Population Health and Chronic Disease Management

• Use the electronic medical record (EMR), patient registries, risk assessments, and population health reports to identify high-risk patients and care gaps.
• Proactively engage patients and help them maintain a strong connection with their primary care medical home.
• Conduct pre-visit planning and prepare daily huddle reports, risk assessments, and patient follow-up priorities.
• Assist providers and care team members in implementing evidence-based practices for preventive care, chronic disease management, and population health.
• Collaborate with patients, families, and clinical team members to develop individualized plans of care.
• Ensure care plans address preventive screenings, disease-specific interventions, treatment goals, and patient self-management goals.
• Enroll eligible patients in chronic care management programs.
• Develop, review, and update chronic disease care plans in collaboration with patients and providers.
• Track pregnancies through delivery to support Uniform Data System (UDS) reporting requirements.

2. Care Coordination and Transitional Care

• Serve as a primary care coordination contact for patients and families.

• Coordinate referrals, specialist appointments, diagnostic testing, follow-up care, and connections to community resources.

• Facilitate timely communication among patients, primary care providers, hospitals, emergency departments, long-term care facilities, specialists, home health agencies, and insurance plans.

• Develop collaborative relationships with hospital admission staff, case managers, discharge planners, and emergency department contacts.

• Obtain medical records, laboratory results, diagnostic reports, and other clinical information needed to support continuity of care.

• Monitor transitions of care and support timely patient outreach and follow-up, including:

• Hospital follow-up appointments within seven days of discharge.

• Emergency department outreach within 48 hours of discharge.

• Emergency department follow-up appointments within 7-14 days of discharge.

• Collaborate with patients, providers, and insurance payers to reduce avoidable emergency department utilization.

• Identify barriers affecting access to care, including transportation, financial, language, health literacy, and social needs.

• Help patients overcome identified barriers by coordinating appropriate services and resources.

• Communicate patient needs, preferences, risks, and barriers to providers and other members of the care team.

• Participate in multidisciplinary care team meetings, case reviews, quality improvement projects, and population health initiatives.

3. Patient Education and Health Coaching

• Assess patients' readiness and need for additional self-management support.
• Use motivational interviewing and other patient-centered coaching techniques to help patients establish and achieve realistic health goals.
• Provide education and support related to chronic disease management, medication adherence, tobacco cessation, nutrition, physical activity, and other healthy lifestyle choices.
• Connect patients and families with appropriate community, healthcare, and social service resources.
• Encourage patients to participate actively in their care plans and healthcare decisions.

4. Team and Organizational Responsibilities

• Maintain accurate, timely, and confidential documentation in the EMR and applicable patient registries.
• Maintain open and effective communication with providers, clinical teams, and office staff regarding patient status and care coordination needs.
• Attend required training, team meetings, and collaboration sessions.
• Protect patient information and comply with HIPAA, organizational policies, and applicable healthcare regulations.
• Perform other duties as assigned.

Required Qualifications

• Current, unrestricted license to practice as a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
• Minimum of five years of relevant healthcare experience.
• Experience in a health center, primary care practice, rehabilitation setting, skilled nursing facility, home health organization, managed care plan, or comparable healthcare environment.
• Experience with care coordination, case management, discharge planning, transitional care, or chronic disease management.
• Current Basic Life Support (BLS) and CPR certification, or ability to obtain certification within the timeframe established by SVCHS.
• Working knowledge of electronic medical records, patient registries, and clinical documentation.
• Proficiency with Microsoft Office, including Word, Excel, PowerPoint, and Outlook.
• Ability to maintain patient confidentiality and properly manage protected health information.
• Strong organizational, prioritization, follow-through, and time-management skills.
• Ability to communicate professionally and compassionately with patients, families, healthcare professionals, community partners, and the public.
• Ability to work independently and collaboratively as part of a multidisciplinary healthcare team.
• Familiarity with community and social service resources that address patients' health-related social needs.

Preferred Qualifications

• Certified Case Manager (CCM) credential.
• Experience working in a Federally Qualified Health Center or Patient-Centered Medical Home.
• Experience using motivational interviewing and patient-centered health coaching techniques.
• Experience with population health management, chronic care management, care transitions, quality improvement, or value-based care.
• Knowledge of Uniform Data System reporting and other health center quality measures.
• Experience working with high-risk, medically complex, or underserved patient populations.

Why Join SVCHS?

At SVCHS, you will have the opportunity to:

• Help patients overcome barriers that affect their health and access to care.
• Work collaboratively with a mission-driven, multidisciplinary healthcare team.
• Support high-risk and chronically ill patients throughout their care journeys.
• Strengthen partnerships among primary care, hospitals, specialists, health plans, and community resources.
• Contribute to better patient outcomes, improved access, and healthier communities across Southwest Virginia.

Equal Employment Opportunity & E-Verify Statement

Southwest Virginia Community Health Systems, Inc. is an Equal Opportunity Employer and is committed to fostering a diverse and inclusive workplace. We do not discriminate in employment opportunities or practices on the basis of race, color, religion, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), sexual orientation, gender identity or expression, national origin, ancestry, age, physical or mental disability, genetic information, marital status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.

We are committed to providing reasonable accommodations to qualified individuals with disabilities and to applicants and employees with sincerely held religious beliefs, in accordance with applicable law.

Southwest Virginia Community Health Systems participates in the E-Verify program. All newly hired employees are required to complete Form I-9 and will have their employment eligibility verified through E-Verify in accordance with federal law.

In compliance with the Immigration Reform and Control Act of 1986, all individuals hired must provide documentation establishing identity and authorization to work in the United States. SVCHS does not use E-Verify to pre-screen applicants and will not take adverse action against an individual based solely on tentative non-confirmation results.

Applicants requiring assistance with the application process due to a disability may contact Human Resources for support.