Registered Nurse of Complex Care Coordination

The Complex Care Coordination RN (HV Region) will strengthen Sun River Health's ability to deliver timely, evidence-based nursing support to patients across the HV region without requiring every site to staff advanced care-coordination expertise on-site. Working within a hybrid framework, the RN will provide telephonic triage, chronic disease coordination, and support to patients and care teams across multiple sites, extending on-site clinical capacity, leveraging standardized best practices, and closing care gaps.

The role will prioritize care coordination for Sun River Health patients with complex chronic conditions in rural HV North locations and provide remote nursing support and supplemental clinical capacity to sites with limited staffing, enabling care teams to manage daily patient-care needs effectively.

Position Summary

The Complex Care Coordination RN is a hybrid registered nurse who supports the coordination and delivery of timely, appropriate, and cost-effective care for patients across multiple HV sites. The RN partners with on-site clinical teams to provide telephonic triage, chronic disease management support, and coordination of timely follow-up for patients.

The Complex Care Coordination RN uses evidence-based protocols to assess symptoms, escalate red-flag findings, close care gaps, and reinforce self-management education, extending nursing capacity to sites without dedicated care-coordination staff on-site. The position is accountable for outcomes that matter in value-based arrangements, health center access metrics, and for the quality, safety, and documentation of every clinical encounter.

Care Coordination & Support to Sites

• Serve as a remote care-coordination resource for assigned HV North sites, partnering with site providers, nurses, medical assistants, and care managers to close care gaps and ensure continuity across settings.


• Identify inpatient, SNF, ED, and behavioral health discharges within 24–48 hours of discharge notification and initiate structured post-discharge outreach to assigned patients.


• Conduct telephone medication reconciliation and renewals in accordance with Sun River Health protocols; support health centers in addressing telephone encounters, assessing patient symptoms and barriers to care access, engaging patients in follow-up appointments, and facilitating warm handoffs to internal Sun River Health programs, DME, transportation, and social services where indicated.


• Ensures integration of patient assessments and engagements with the site primary care clinical teams through appropriate communication channels.


• Coordinate longitudinal care with primary care, specialty, hospital, home-health, and community-service partners; ensure information transfer to the site care team via the EHR and closed-loop communication.


• Support site teams with prior authorizations, referrals, and clinical follow-up of patient needs when local capacity is limited. 


• Track and meet Transitional Care Management (TCM) and Complex Care Coordination requirements where applicable for reimbursement of eligible services provided.


• Deliver telephonic patient education on medications, symptom management, self-care measures, and appropriate use of urgent and emergency services.


• Identify red-flag symptoms (e.g., chest pain, respiratory distress, new neurologic changes, suicidal ideation) and promptly escalate to the provider, on-site RN, or emergency services following organizational escalation pathways.


• Conduct structured symptom assessments, apply clinical judgment within the RN scope of practice, and recommend the appropriate level of care (self-care with education, same-day appointment, urgent care, ED, or 911).


• Maintain accurate, real-time documentation of all coordination activities in the electronic medical record to preserve continuity and maintain compliant record-keeping.

Qualifications

• Current, unencumbered Registered Nurse (RN) license in the State of New York.


• BSN preferred; ADN considered 


• Care coordination, care management, transitions of care, or telehealth/triage experience strongly preferred.


• Experience with chronic disease management (CHF, diabetes, hypertension) and evidence-based patient education.


• 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.

Salary Range: $45.45-$55.15/hour

Relation to Mission
The mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.

Equal Employment Opportunity
Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function.

Americans with Disabilities Act
Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

Job Responsibilities
The following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of the position. Sun River Health may change the specific job duties with or without prior notice based on the needs of the organization.