Care Coordinator at Hunterdon Health Care System – Clinton, New Jersey

Care Coordinator

Position Summary

The Care Coordinator supports patients and the clinical care team within an outpatient primary care setting by facilitating care coordination, improving access to resources, and ensuring continuity of care across the healthcare continuum. This role focuses on supporting patients with chronic conditions, coordinating services following hospital or emergency department visits, and assisting patients in navigating healthcare services and community resources.
The Care Coordinator will perform Transitional Care Management (TCM) outreach, assist with durable medical equipment (DME) coordination, and support patients with complex medical and social needs. The position plays a key role in improving quality outcomes, patient experience, and care transitions.
This position will also participate in the development and implementation of care coordination programs, including piloting care coordination billing initiatives. As the program evolves, responsibilities may adapt to support operational needs, workflow improvements, and new value-based care initiatives.

Primary Position Responsibilities

1. Care Coordination & Patient Navigation

Coordinate care for patients with chronic or complex medical conditions in collaboration with primary care providers and the care team.
Assist patients in navigating the healthcare system, including referrals, specialty care coordination, and follow-up appointments.
Support patients in accessing appropriate medical, behavioral health, and community-based services.
Identify and address barriers to care including transportation, medication access, equipment needs, and social determinants of health.

2. Transitional Care Management (TCM)
Conduct post-discharge outreach calls to patients following hospital or emergency department visits in accordance with TCM guidelines.
Review discharge instructions, medication reconciliation needs, and follow-up care requirements.
Coordinate timely follow-up appointments and ensure continuity of care with the primary care provider.
Document outreach and coordination activities in the electronic medical record.

3. Durable Medical Equipment (DME) & Resource Coordination
Assist patients with ordering and coordination of durable medical equipment and medical supplies.
Facilitate communication between providers, vendors, and patients regarding equipment needs.
Connect patients to community resources, support programs, and social services as appropriate.

4. Quality & Population Health Support
Support quality improvement initiatives related to chronic disease management and preventative care.

Assist with outreach to patients for preventative screenings, chronic care follow-up, and care gap closure.

Collaborate with the care team to improve patient outcomes and adherence to treatment plans.

5. Program Development & Innovation
Participate in the implementation and evaluation of care coordination initiatives.
Support pilot programs related to care coordination billing and documentation requirements.
Assist in refining workflows and processes as care coordination services evolve.

Demonstrate flexibility as program priorities develop and operational needs shift.

6. Documentation & Communication
Accurately document all patient interactions and care coordination activities in the electronic medical record.
Maintain communication with providers, clinical staff, patients, and external partners to ensure coordinated care.
Maintain confidentiality and comply with all organizational and regulatory requirements.

Qualifications

Minimum Education:

Required:

Associate or Bachelor’s degree in nursing.

Preferred:

None

Minimum Years of Experience (Amount, Type and Variation):

Required:

2+ years of experience in a healthcare setting, preferably in primary care, care coordination, case management, or population health. Experience working with patients with chronic medical conditions preferred.
Familiarity with transitional care management and care coordination processes preferred.

Preferred:

Five years of medical/surgical hospital based direct patient care experience and Care coordination or Case Management experience.

License, Registry or Certification:

Required:

Current NJ RN licensure

Preferred:

Certification in Specialty or Case Management Certification

Knowledge, Skills and/or Abilities:

Required:

Strong understanding of healthcare systems, care transitions, and patient navigation. Knowledge of chronic disease management and preventative care principles. Excellent communication and patient engagement skills.
Strong organizational and problem-solving abilities.
Ability to work collaboratively within an interdisciplinary care team. Proficiency with electronic medical records and healthcare documentation

Preferred:

None

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).