Care Coordinator

RN Care CoordinatorThe RN Care Coordinator provides advanced care coordination in the ambulatory setting, using independent nursing judgment for triage, clinical decision-making, management of patient needs, and guiding patients through the health system. The role functions as a central clinical resource, overseeing triage, clinical inbox management, medication oversight, and assists with creating and implementing clinical pathways, policies, and services. This position manages RN-level clinical tasks that support safe, efficient care and help providers practice at the top of their license. The RN Care Coordinator acts as a patient advocate and liaison among patients, families, providers, and clinical teams, promoting access, education, timely care, and continuity of care while practicing with a high level of autonomy within established protocols.Education, Licensure, and Experience:Bachelor's degree in Nursing requiredCurrent and valid Registered Nurse license in the Commonwealth of Virginia or from a state that is part of a Compact agreement with Virginia required.Ambulatory Care Nursing Certification (AMB-BC) preferredCPR requiredPrevious computer experience to include EHR and use of database applications requiredPrevious ambulatory office experience preferred.Essential Job Duties:Clinical Triage & Care Coordination:Perform comprehensive RN-level clinical triage for incoming patient phone calls, walk-in encounters, electronic messages, abnormal test results, and referrals using evidence-based protocols, standing orders, and independent nursing judgment.Assess patient-reported symptoms, vital sign trends, acuity, comorbidities, and clinical risk factors to determine appropriate disposition, including same-day provider evaluation, nurse visit, outpatient management, urgent care referral, or emergency department escalation.Collaborate with providers to facilitate same-day or expedited care when no appointment availability exists, including prioritization of high-risk patients and coordination of urgent follow-up.Provide real-time patient education, clinical guidance, and safety instructions within RN scope of practice, ensuring patient understanding and adherence through teach-back, written instructions, and individualized communication strategies.Coordinate care transitions following emergency department visits, hospitalizations, procedures, or diagnostic testing, including follow-up planning, medication reconciliation, and patient education.Meet patients where they are in terms of health literacy, cognitive ability, and social circumstances, adjusting education and care plans accordingly to reduce barriers to safe and effective care.Provider Inbox & Clinical Result Management:Serve as the primary RN responsible for active management of assigned provider inboxes, clinical result queues, and patient communication buckets, identifying, prioritizing, and addressing time-sensitive and high-risk items.Perform RN-level assessment of inbox messages, abnormal laboratory results, and imaging findings to determine urgency, clinical significance, and appropriate next steps.Independently address and resolve inbox items within RN scope of practice using approved protocols and standing orders, including patient outreach, education, monitoring plans, and follow-up scheduling, and escalate as appropriate.Communicate abnormal laboratory and imaging results directly to patients, provide provider interpretation and recommendations, deliver patient education on diagnosis, lifestyle modification, medication management, and outline plans for repeat testing or follow-up.Escalate clinically complex, high-risk, or out-of-scope findings to providers with clear clinical summaries, risk assessment, and recommendations, supporting efficient and informed provider decision-making.Ensure closed-loop communication, timely documentation, and follow-up to mitigate risk of missed results, delayed care, or patient harm.Medication & Prescription Management:Manage high-volume prescription refill requests originating from patients, requiring RN clinical review to verify appropriate prescribing provider, confirm required follow-up intervals (3, 6, or 12 months as indicated), and assess medication safety prior to refill authorization.Identify and address potential drug interactions, contraindications, side effects, adherence concerns, and risks related to polypharmacy, particularly in patients with multiple chronic conditions.Provide extensive medication education to patients and family members, including safe administration, dosing schedules, side effect monitoring, and medication-specific precautions.Provide same-day, hands-on education for patients newly initiated on insulin therapy, including safe drawing and administration techniques, individualized written instructions, vial or pen color-coding, and use of recorded instructions when needed.Coordinate and perform nurse visits to assist patients with application, setup, and education for Continuous Glucose Monitoring (CGM) devices.Make RN-directed clinical decisions such as instructing patients to temporarily hold medications (e.g., antihypertensives, beta blockers, insulin, GLP-1 agonists, etc.) when clinically indicated, with provider guidance and collaboration and follow-up.Instruct patients to maintain and report blood pressure, heart rate, and blood glucose logs, assess trends, and escalate concerns appropriately.Collaborate with pharmacies and insurance providers to resolve prescription issues, including signature clarification, quantity adjustments, refill authorization, and identification of therapeutic substitutions covered under insurance plans.Laboratory, Imaging & Diagnostic Coordination:Order routine laboratory testing for annual visits and chronic disease monitoring in accordance with standing orders and clinical protocols.Order laboratory testing based on RN clinical phone assessment and triage findings when appropriate.Communicate abnormal laboratory results to patients, provide education on normal and abnormal values, and review plans for repeat testing or treatment adjustments.Order routine imaging studies including mammograms, low-dose CT scans (LDCT), DEXA scans, and other preventive diagnostics per protocol.Communicate abnormal imaging results to patients, relay provider recommendations, coordinate appropriate referrals, and ensure follow-up plans are clearly understood.Identify and apply clinically appropriate diagnosis codes for labs, imaging, and referrals to optimize insurance coverage and reduce barriers to care.Patient Access Optimization:Independently place, manage, and track internal and external referrals requiring RN clinical assessment, including physical therapy, occupational therapy, audiology, case management, social work, radiology, and other specialty services.Evaluate referral appropriateness based on clinical presentation, patient needs, and provider input.Collaborate with providers when clarification or shared decision-making is required regarding referral necessity or urgency.Partner with Aya Healthcare