RN Care Coordinator - IMA Medical Group

Job Description Summary

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We are excited to announce an opening for RN Care Coordinator in our Polk County area! The RN Care Coordinator supports patients experiencing emergency department visits and hospital inpatient admissions by coordinating care across hospitals, primary care providers, patients, caregivers, and interdisciplinary care teams.

This role facilitates timely transitions of care, identifies clinical and social barriers, provides patient and caregiver education, and coordinates appropriate follow-up services to improve outcomes and reduce avoidable emergency department visits and hospital readmissions.

The position includes remote coordination and on-site visits to local hospitals and primary care clinics.
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How will you make an impact & Requirements

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Key Responsibilities

- Review hospital portals and Health Information Exchange (HIE) report daily to identify and monitor inpatient admissions, emergency department visits, transfers, and discharges.
- Review relevant clinical information, assess patients’ risk and care needs, and identify clinical, medication-related, and social barriers that may contribute to avoidable utilization or readmission.
- Conduct hospital visits and initial and ongoing patient follow-up during inpatient admissions and emergency department encounters, as appropriate to patient needs.
- Coordinate transitions of care beginning during hospitalization, including discharge planning, follow-up appointments, medication management, home health, durable medical equipment (DME), specialty referrals, and other post-acute services.
- Collaborate with hospitalist teams, primary care providers (PCPs), clinic Care Managers, and other interdisciplinary team members to align treatment plans, address barriers to discharge, and support safe transitions of care.
- Facilitate timely primary care follow-up and help patients and caregivers access appointments, transportation, and appropriate clinical support to reduce avoidable emergency department visits and hospital readmissions.
- Educate and support patients and caregivers regarding diagnoses, symptom recognition and management, medication adherence, discharge instructions, and available healthcare and community resources.
- Reinforce appropriate use of healthcare services, including when to contact the PCP or Care Management team, seek urgent or same-day care, contact the on-call provider, or seek emergency care.
- Communicate timely updates regarding hospitalizations, emergency department encounters, discharge plans, patient status, and follow-up needs to PCPs and appropriate provider and clinical team members.
- Participate in clinic huddles and collaborate with providers, Care Managers and referral coordinators to review high-risk patients, frequent emergency department users, and patients requiring additional post-discharge support.
- Participate in care management department meetings, interdisciplinary discussions, and performance improvement initiatives.
- Document hospital encounters, patient interactions, assessments, care coordination activities, outreach attempts, patient education, referrals, escalations, and follow-up plans accurately and within established timeframes, including same-day documentation when required.
- Verify patient demographic and contact information, maintain confidentiality, and adhere to established workflows, documentation standards, HIPAA requirements, regulatory and payer requirements, and organizational policies.
- Complete assigned follow-up actions and support organizational goals related to patient engagement, care quality, patient satisfaction, and reduced avoidable healthcare utilization.

Required Qualifications

- Degree in Nursing
- 3+ years of experience in the hospital and/or clinic setting
- Valid Registered Nurse (RN) license in the state of Florida
- CPR/BLS certification.
- Strong clinical knowledge and skills, with the ability to make critical decisions in fast-paced settings.
- Excellent communication and interpersonal skills.
- EMR Experience
- Proficient with Microsoft suite of products (Teams, Outlook, Excel, Word, PowerPoint)

Preferred Qualifications

- Experience with Athena EMR.
- Bilingual (English and Spanish).
- Experience in care management workflows, including transitions of care.
- Experience in value-based care, Medicare Advantage, or population health.
- Knowledge of CMS, HEDIS, and Medicare Star Ratings quality measures.

About IMA Medical Group

IMA Medical Group is a visionary and dynamic company focused on high-quality primary care services, with doctors and professionals dedicated to the health and well-being of the elderly. With multiple locations throughout Central Florida, we reiterate our commitment to providing quality medical care and an exceptional experience on each visit. That is the peace of mind and convenience that our patients deserve.

About Millennium Physician Group

Formed in 2008 and headquartered in Fort Myers, Florida, with offices in Florida, North Carolina, Georgia, and Texas, Millennium Physician Group is one of the largest comprehensive primary care practices in Florida, serving communities through a value-based care model focused on improving patient outcomes and enhancing the healthcare experience. As part of Mosaic Health, MPG is committed to delivering coordinated, patient-centered care while partnering with health plans, providers, and community organizations to improve the health of the populations it serves.

What We Offer

- Health, Dental, and Vision Insurance
- 401(K) Retirement Plan with Matching
- Employer-Paid Life Insurance Short & Long-Term Disability
- Paid Time Off, Floating Holidays, and Paid Major Holidays
- Employee Assistance Program (EAP)

How to Apply

ARE YOU READY TO JOIN OUR TEAM?  We understand your time is valuable, and that is why we have a very quick and easy application process. If you feel that you are right for this position, please fill out our initial  3-minute, mobile-friendly application  so that we can review your information. We look forward to meeting you!

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Compensation Range:
$77,417.00
to
$116,126.00

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.