Registered Nurse Care Coordination Primary Care

Registered Nurse

Serves in an expanded nursing role as part of an interdisciplinary team, delivering comprehensive care coordination, patient education, and nursing support across the primary care continuum. Responsibilities include triaging clinical concerns, supporting chronic disease management, and facilitating smooth care transitions through phone, patient portal, and in-person interactions. This RN assesses patient needs to determine the appropriate level of care and ensures timely access to services and resources. This role is central to care team communication, patient advocacy, and alignment with evidence-based practices. Additionally, the RN performs Medicare Annual Wellness Visits in collaboration with providers, supporting preventive health efforts and individualized care planning.

Essential Functions:

1. Conduct initial and ongoing patient assessments to evaluate patients' medical needs, understanding of their condition, and urgency of care needs.
2. Triage and prioritize patient concerns, including medical issues, prescription refills, and referral or insurance-related requests, documenting all interactions in the patient chart.
3. Use clinical judgement, standing orders, and established protocols to determine appropriate patient disposition.
4. Develop, execute, and update individualized chronic disease self-management plans using protocols to improve outcomes for patients with complex or chronic conditions—particularly for diabetes.
5. Apply motivational interviewing and patient engagement strategies to enhance adherence and health literacy.
6. Collaborate with providers and patients to close care gaps, monitor health outcomes, and ensure adherence to evidence-based clinical guidelines.
7. Coordinate and navigate care pathways to enhance discharge planning, follow-up scheduling, and connecting patients to appropriate providers to ensure timely access to resources.
8. Facilitate scheduling and follow-up appointments to ensure continuity of care and prevent hospital readmissions or unnecessary ER visits.
9. Coordinate patient referrals, pre-certification and pre-authorizations and appointments to outpatient facilities, specialists and hospitals including preparing insurance referrals, obtaining insurance pre-authorizations, explaining procedures, treatments, prep instructions and medication changes to patients and family members when appropriate.
10. Communicate effectively across care teams to maximize care coordination and ensure alignment on patient care plans.
11. Advocate for patients and families across the healthcare continuum to ensure comprehensive, patient-centered care.
12. Contribute to performance improvement initiatives and stay current with healthcare trends and best practices.
13. Provide general nursing care and education to patients. Administer prescribed medications and treatments in accordance with nursing standards under the direction of the provider.
14. Contact patients to notify of test results and care instructions, according to physician instructions.
15. Call pharmacies with patient prescriptions according to physician's instructions and protocol.
16. Performs Medicare Annual Wellness Visits for patients who qualify for the services, per Medicare guidelines, under supervision of a provider.

Non-Essential Functions:

• Performs related and miscellaneous duties as assigned.

About Us:

Why Mount Nittany Health? At Mount Nittany Health, we provide high-quality patient care with a unique combination of the latest in clinical technology and compassionate medical professionals. We are committed to improving both the quality and availability of healthcare in our region and seek to hire only the best to support the communities we serve.