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Registered Nurse Care Coordinator (san rafael)

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The RN Care Coordinator, in partnership and collaboration with other health care professionals, has a primary focus of engaging MCC patients in care coordination programs. The RN Care Coordinator will serve high-risk, complex patients to maintain and improve patients’ functional status, increase their capacity to self-manage their condition, and reduce their need for acute care services.


Provide culturally-sensitive, patient-centered care to all MCC patients.
Develop and maintain good rapport and trusting relationship with MCC patients and staff.
Providing nursing care within scope of license and clinic policy and procedures.
Works with program development of Intensive Outpatient Case Management Program (IOPCM) and the Affordable Care Act’s Health Homes Program (HHP).
Work with clinical and non-clinical care coordination staff to ensure that deliverables are met for MCC’s care coordination programs.

Actively identify and enroll patients for care coordination based on eligibility criteria.
Perform initial nursing assessment and needs assessment on new referrals to the care coordination program.
Perform chart review prior to initial assessment to inform patients’ annual care plan and individualized action plan.
Participate in developing comprehensive care plan with and for patients and coordinate care as outlined in care plan.

Provide regular follow-up and maintain contact with clients as needed to assure completion of care plan, and provide regular feedback to primary provider of care and staff regarding clients’ progress.
Work closely with Primary Care Provider to manage patient “Care Items” which could include: medication refills per protocol, lab triage, document management, management of durable medical equipment, prior authorizations of needed medications or other services, and other items as needed.
Provide Nurse visits for designated conditions per clinical protocol.
Coordinate tracking of patients for follow-up and continuity of care which may include.
Coordinate tracking of patients’ outcome measures and clinical assessments.
Participate in Care Team meetings to include daily huddles, monthly care team meetings, complex care case conferences and other related meetings.
Participate in quality improvement, quality assurance, and innovation activities to ensure optimal level of care at MCC.

Facilitate care transitions from ER or Hospital to SNF or home.
Connect patients with MCC’s Patient Care Navigator and/or other social services in Marin County as needed.
Maintain current knowledge of community resources and develop working relationships with those resources for clients.
Perform medication reconciliations, evaluate medication adherence and effectiveness, and recommend or make guideline-directed changes in regimen.
Provide medication education, management, and monitor patient adherence.
Provide emotional support and monitor psychosocial state, recommending appropriate mental health or supportive interventions when necessary.
Perform and oversee all care coordination duties necessary to successfully implement the plan of care.
Act in a leadership role with non-clinical care coordinators when needing guidance regarding patient care and/or other issues.


Nursing degree
Active California RN License in good standing
Current AHA CPR Certification
Excellent verbal and written skills
Bilingual in Spanish desired
Strong critical thinking skills required
Must be able to work independently, with written protocols
Must be sensitive to ethnic and cultural differences and their relevance to health care
Desired Additional Qualifications
Experience in a community clinic or primary care setting.
Familiarity or proficiency in using NextGen Electronic Health Records or i2i Tracks.
Experience with nursing care coordination/ case management.
2+ years of experience as an RN in a primary care/ community health setting.
Ability to problem-solve and have acute attention to detail.
Must have excellent written and oral skills, as well as strong organizational and analytical skills.
Must have ability to manage priorities and workflow.
Strong interpersonal skills and ability to work well with a multidisciplinary team.
Demonstrate a positive customer service, patient-centered approach at all times.
Travel Requirements
Ability to drive to the various MCC clinic sites (Larkspur, San Rafae) as needed.
Ability to attend off-site care coordination trainings (can include but is not limited to travel in North Bay such as Petaluma and Santa Rosa).

To Apply to this job Please go to website address given in Source below

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