About this role
Job Title
Clinical Coordinator Rural Health
Reports To
Director of TOC
Location
HV North/Hybrid
FLSA Status
Exempt
Salary Range
$77,768.60/year - $100,828.00/year
Position Summary
The Rural Health Clinical Coordinator supports the coordination and delivery of timely, appropriate, and cost-effective care for patients residing in rural communities. This position works across transitions of care, high-risk care management, and care coordination to reduce avoidable emergency department visits, hospitalizations, readmissions, and gaps in care.
The Clinical Coordinator leads proactive, team-based care for patients who are at high risk for readmissions, emergency department use, or fragmented care. This role coordinates transitions of care (TOC), delivers high-touch care management, and conducts reviews to ensure continuity of care, appropriate level of care, and cost-effective service use across the continuum.
- Identify patients in Dutchess County with high needs and/or high utilization
- Develop and support ongoing partnerships with hospital discharge planning to ensure smooth coordination for transitions of care
- Engage and support patients with high needs/high utilization to appropriate levels of care and increase utilization of primary care
- Develop and utilize appropriate protocols focused on complex care including CHF, DM, CVD, SUD and BH
- Coordinate longitudinal care for patients with complex chronic conditions across primary care, specialty, hospital, home-health, and community-service settings, with a special focus on rural regions of the Sun River Health network.
- Conduct structured patient outreach after emergency department visits and hospital discharges to evaluate symptoms, medication access, follow-up needs, and barriers to care.
- Identify discharges from inpatient, SNF, ED, and behavioral health settings within 24–48 hours of discharge notification.
- Use established clinical protocols to identify red-flag symptoms and promptly escalate concerning findings to the RN, provider, or emergency services as appropriate.
- Reinforce individualized self-management education for chronic conditions.
- Coordinate warm handoffs to community resources (home health, DME, transportation, social services) and ensure information transfer to the care team
- Maintain a defined panel of high-risk patients (e.g., multiple chronic conditions, recent hospitalizations, SDOH barriers) and stratify risk using EHR/registry data.
- Develop individualized care plans with goals, self-management support, and escalation pathways; engage patients/caregivers using motivational interviewing and health coaching.
- Coordinate multidisciplinary huddles with PCPs, specialists, behavioral health, pharmacy, and social work to address complex needs and avoid avoidable utilization.
- Document care management encounters and outcomes in the EHR/care management platform
Qualifications
- Current, unencumbered Licensed Practical Nurse (LPN) license in the State of New York.
- Proficiency with electronic health records and standard office productivity tools; comfort with telehealth technology and secure remote communication.
- Strong clinical assessment, critical thinking, and prioritization skills in a remote, high-volume environment.
- Excellent verbal and written communication skills; ability to build rapport with patients and cross-site teams in person, by phone, and video.
- Cultural humility and experience serving diverse, underserved, and rural communities preferred.
- Bilingual (English/Spanish) preferred.
- CPR/BLS certification current.