Job Summary

The Care Coordination Nurse plays a critical role in delivering high-quality chronic care management (CCM) services to patients with complex medical conditions. The nurse will support patients through monthly outreach, care planning, and health coaching to improve long-term health outcomes and reduce unnecessary hospital utilization. This role requires strong clinical judgment, attention to detail, and a passion for patient-centered care.

Qualifications and Experience:

• Licensure: Active LPN license in Pennsylvania required; RN strongly preferred.

Skills:

• Strong communication and interpersonal skills
• Proficient in navigating EHRs and digital communication tools
• Ability to work independently and manage a patient panel

Experience

·Experience: Minimum of 2 years of nursing experience in a clinical, community health, or care coordination role.

• Experience in primary care, family medicine, or community health settings (Preferred)
• Experience with chronic care populations preferred
• Experience in delivering care coordination in a remote position to set up FHCP for transitions of care, ER diversion/follow up, and appointment scheduling.

Competencies:

·      Patient-Centered Care

·      Health Education & Coaching

·      Clinical Documentation

·      Interdisciplinary Collaboration

Core Values

Teamwork

How this is demonstrated in this role:

• Collaborates closely with providers, care teams, and FairHill Health staff to ensure coordinated patient care.
• Actively participates in case reviews and team huddles to share insights and improve patient outcomes.
• Supports colleagues by sharing best practices and helping to cover caseloads as needed.

 

Adaptability

How this is demonstrated in this role:

• Adjusts care plans in real time based on evolving patient needs, health status, or life circumstances.
• Navigates multiple systems and technologies (EHRs, telehealth platforms, reporting tools) with flexibility.
• Embraces changes in workflows or regulatory guidelines while maintaining high-quality service.

 

Communication

How this is demonstrated in this role:

• Maintains clear, compassionate, and culturally sensitive communication with patients and families.
• Effectively relays patient updates and concerns to providers and clinical supervisors in a timely manner.
• Uses written documentation and verbal updates to ensure continuity of care and accurate records.

Accountability

How this is demonstrated in this role:

• Follows through on outreach, documentation, and follow-ups with consistency and integrity.
• Maintains accurate, timely records in compliance with organizational and CMS guidelines.
• Makes responsibility for meeting performance metrics and proactively addresses barriers to success.

Essential Functions

• Perform monthly outreach to assigned patients enrolled in the Chronic Care Management (CCM) program.
• Demonstrate the ability to deliver large volumes of phone calls and emails support to patients.
• Utilize a person-centered approach to review and update care plans, assess patient health status, and promote engagement in self-management.
• Document all interactions and updates in the electronic health record (EHR) in accordance with CMS and FHCP documentation standards.
• Collaborate with FHCP providers to ensure alignment of patient care plans.
• Address patient questions related to medications, test results, appointments, or clinical instructions; escalate to providers as necessary.
• Monitor and report changes in patient conditions, adherence concerns, or emerging social determinants of health.
•  Educate patients on managing chronic conditions, lifestyle modification, and treatment adherence.
• Assist in identifying patients who may benefit from community-based resources or additional clinical support.
• Maintain compliance with HIPAA and all applicable privacy and security protocols.

Physical Requirements, Physical Demands and Work

Environment Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. To request accommodation, contact Human Resources. FHCP is committed to compliance with federal, state, and local laws regarding individuals with disabilities.

 

Fair Hill Community Physicians is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected category. We believe in the power of diversity and encourage candidates from all backgrounds to apply.