Deacon Health

Description

Overview:

The Patient Coordinator (RN) serves as the primary point of contact for patients participating in value-based care programs beginning at the onset of a care episode and continuing through recovery. This person will provide proactive clinical support, education, and care coordination, designed to improve patient outcomes while reducing unnecessary utilization and hospital readmissions.

This role is responsible for engaging patients as early as possible in their healthcare journey - often immediately following diagnosis, hospital admission, or referral into the care management program. - to ensure patients understand their care plan, access the right resources, and receive appropriate support throughout the episode of care.

The Patient Coordinator builds trusted relationship with patients and caregivers, proactively identifying clinical or social barriers that could lead to complications, avoidable emergency visits, or hospital readmissions. Through continuous engagement, education, and clinical assessment, the coordinator helps guide patients through the healthcare system, ensuring timely follow-up care and adherence to treatment plans.

Because this role requires overnight patient engagement and triage support candidate must hold an active Registered Nurse (RN) license and demonstrate strong clinical assessment skills.

Primary Responsibilities and Essential Duties:

The responsibilities of this role will include but will not be limited to the following:

Early Episode Engagement

• Initiate patient outreach at the beginning of the care episode, including hospital admission, discharge planning, referral into our value-based care program, or identification as a high-risk patient.
• Introduce the Patient Coordinator program and establish a trusted relationship with patients and caregivers from the outset of care.
• Ensure patients understand their diagnosis, care plan, medications, and next steps.
• Identify potential barriers to recovery early, including transportation, medication access, social determinants of health, or caregiver support needs.

Patient Coordination and Ongoing Support

• Serve as primary clinical contact for patients throughout their episode of care, providing guidance and support from initial engagement through recovery and program graduation.
• Respond to patient concerns or symptoms that arise outside of normal provider office hours.
• Provide clinical triage and guidance, including:
• Self-care instructions
• Urgent care referral
• Escalation to on-call physicians or clinical teams
• Offer reassurance and coaching to patients experiencing symptoms or uncertainly overnight
• Conduct proactive outreach calls to monitor patient progress and ensure adherence to care plans.
• Provide coaching, education, and support to patients and families navigating complex healthcare systems.
• Act as a consistent point of contact to help patients avoid unnecessary emergency department visits or hospital readmissions.
• Conduct structured post-discharge follow-up and monitoring to identify early signs of complications.
• Ensure patients complete timely follow-up appointments with primary care providers and specialists
• Address medication adherence issues 
• Escalate clinical concerns to physicians or care teams when early warning signs are identified
• Document all patient interactions, risk factors, and interventions within the care management platform
• Coordinate closely with physicians, discharge planners, case managers, and other healthcare providers to ensure continuity of care.
• Facilitate access to services such as home health, rehabilitation, transportation, and durable medical equipment.
• Connect patients with community resources and support services when needed. 

Requirements

Qualifications

• Associate's or Bachelor's degree in Nursing (BSN preferred)
• An active nursing license in good standing is REQUIRED for this role
• 3+ years of clinical nursing experience preferred
• Experience in care management, case management, population health, or telehealth.
• Experience working with high-risk patient populations
• Familiarity with value-based care models (ACO, Medicare Advantage, bundled payment, or risk contracts preferred)
• Strong clinical triage and patient assessment skills
• Exceptional patient communication and empathy
• Ability to establish trust quickly with patients and caregivers
• Strong care coordination and organizational skills
• Comfort working with remote care technologies and EMR systems is a must
• Ability to remain calm and decisive in overnight clinical situations.