Registered Nurse Specialist, Care Coordinator

Job Description

Job Description

Job Description

Finger Lakes Community Health uses BambooHR for the hiring and onboarding of our staff. All communications for recruitment will come directly from BambooHR (View email address on ziprecruiter.com) and may appear as spam.

About Finger Lakes Community Health:

Finger Lakes Community Health (FLCH) was founded in 1989 with an original mission of serving the region's agricultural workers by linking individuals to area resources and providing essential health services. In 2009 the organization expanded to become a Federally Qualified Health Center (FQHC), serving patients of all incomes, ethnicities and walks of life. Over the last decade, FLCH has grown to provide medical, dental, and behavioral health services to over 28,000 patients at eight health centers. With over 200 employees we strive to provide high-quality and innovative health care services to the Finger Lakes Region.

Benefits Offered:

• Monday through Friday schedule, closed all major holidays
• Medical insurance with a 90% employer contribution
• Dental, Vision, and Life insurance
• Safe Harbor 3% 401k contribution
• Robust PTO offerings 
• Education reimbursement 

Job Summary :  

The RN Specialist – Care Coordinator improves health outcomes for patients with complex and chronic conditions, including diabetes. The role supports patients across the care continuum by coordinating treatment plans, reducing fragmented care, and ensuring smooth transitions between services.

Main Responsibilities:

Care Coordination & Patient Support
• Coordinate care and services for patients with complex needs, including diabetes and other chronic conditions.
• Provide guidance to patients and families on treatment plans, medications, and self-management strategies.
• Support safe and effective transitions of care to help prevent avoidable hospital readmissions.
• Collaborate closely with primary care providers, behavioral health clinicians, RNs, care managers, and external specialists to support integrated, team-based care.
• Facilitate referrals to specialty care, diagnostic services, emergency care, or community resources based on patient needs.
• Participate in multidisciplinary reviews, care team huddles, and care planning discussions to ensure coordinated, patient-centered treatment.
Assessment & Care Planning
• Conduct nursing assessments to identify medical, behavioral, social, and environmental needs.
• Identify barriers to disease management—such as medication access, health literacy, or social determinants—and incorporate findings into care plans.
• Advocate for patients by addressing barriers to care, assisting with resource navigation, and promoting seamless coordination across services.
• Develop individualized plans of care and help patients establish realistic health goals.
• Monitor progress, review clinical indicators (e.g. diabetes measures such as A1c), and adjust care plans.
Program Development & Coordination
• Identify care gaps and collaborate with Population Health to develop targeted care coordination programs.
• Support the implementation and evaluation of chronic disease and diabetes-related initiatives.
• Serve as a liaison between clinical teams and community agencies to enhance care coordination.
Education & Team Collaboration
• Provide education and guidance to patients, families, and care teams on chronic disease management, diabetes care, and care coordination processes.
• Reinforce disease management strategies, including medication adherence and healthy lifestyle practices.
• Participate in team discussions and support clinical staff in addressing complex patient needs.
• Participate in performance improvement activities and recommend strategies to improve quality measures and meet organizational goals, including diabetes and chronic disease benchmarks.

• Scan clinical documents from patient or clinical staff into patient chart.
• Chart services in patient record including but not limited to:
o Referrals, medications, vaccinations, injections, screenings, lab orders/results, patient care goals, patient history, vitals
• Chart and lock notes within timely manner in accordance with Finger Lakes Community Health policies and procedures.
Other Duties
• Perform other related duties as assigned by the supervisor.

Physical Requirements: 

• Sitting/Standing: Prolonged sitting with occasional standing or walking.
• Computer Use: Frequent typing and prolonged screen time.
• Moderate Lifting: Regularly lifting or carrying items weighing between 15-40 pounds.
• Visual: Clear vision for reading and inspections.
• Hearing Clarity: Ability to hear conversations in person or in virtual communications.
• Noise Sensitivity: Work may require filtering background noise to focus on speech or signals.
Work Environment
• Health Center/Clinic: Work within a healthcare facility, interacting with patients and staff.
• Moderate-Paced: Dynamic environment that requires both productivity and accuracy to reach goals and project objectives.
• Office Hours: Standard business hours, with occasional extended shifts based on clinic needs.

Education and Qualifications:

• Associate or bachelor’s degree in nursing is required.
• Master’s degree in nursing is preferred.
• Certification or diploma from an accredited nursing program.
• 3+ years in a healthcare or customer service setting, acting as a subject matter expert and operating independently required.
• A valid government-issued photo identification document is required.
• Current CPR certification through a HRSA accepted agency is required (can be provided upon employment).
• A current, unrestricted, NYS Registered Nurse license is required.
• Completion of continuing education in accordance to NYS licensing renewal and privileging requirements.
• Exhibits depth of knowledge in designing and evaluating health interventions within communities.
• Advanced knowledge in primary care models and chronic disease management.
• Leads improvement of techniques and practices from data results.
• Applies advanced expertise to identify complex and recurring challenges.
• Able to effectively manage time across complex assignments.