- Location106 Congress St, Bangor, ME, 04401, United States
- Base Pay$38.00 – $42.00 / Hour
- Employee TypeFull-Time Exempt
- Required Degree4 Year Degree
- Minimum Experience3 Years
Contact information
- NameTracey MacDonald
- Email[email protected]
Description
Position Summary: Registered Nurse (RN) Care Coordinator- Fully Remote
This is a full-time, fully remote position; candidates must reside in Maine.
Are you a nurse who is passionate about building meaningful relationships with patients, supporting them through vulnerable transitions, and helping them take control of their health?
Community Care Partnership of Maine is seeking a Registered Nurse (RN) Care Coordinator – Primary Care to support patients after hospital, skilled nursing facility, and emergency department visits, as well as patients living with chronic or complex health conditions.
The RN Care Coordinator provides transitional care management, chronic care management, medication-safety support, proactive outreach, patient education, care planning, and coordination with the broader care team. This role helps patients understand their care plans, medications, follow-up needs, and available supports while addressing barriers to recovery and ongoing care.
The RN Care Coordinator / Chronic Care Manager serves as a key clinical resource for patients navigating care after a hospital or emergency department visit and for those living with chronic health conditions. This role supports transitional care management, chronic care management, medication-safety initiatives, and value-based care goals through proactive outreach, patient education, care planning, and close collaboration with the broader care team.
The RN Care Coordinator works directly with patients following discharge to help ensure they understand their care plan, medications, follow-up needs, and available supports. The role also partners with patients over time to manage chronic diseases, address barriers to care, set achievable health goals, and connect them with clinical, pharmacy, behavioral health, and community-based resources.
Working collaboratively with primary-care teams, pharmacists, specialists, hospitals, and community partners across the healthcare network, this nurse helps create smooth transitions, reduce avoidable gaps in care, and promote coordinated, safe, and effective patient-centered care. This is an ideal role for an RN who enjoys relationship-based care, patient advocacy, education, problem-solving, and making a meaningful difference outside of a traditional bedside setting.
Care Coordination
- Provide timely outreach to patients following discharge from the hospital, skilled nursing facility, or emergency department to support a safe transition back to primary care.
- Complete post-discharge clinical assessments, medication reconciliation, patient and caregiver education, and coordination of timely follow-up appointments.
- Identify and address barriers to recovery and ongoing care, including medication access, transportation, health literacy, behavioral health, social needs, and connection to community resources.
- Provide ongoing chronic care management for patients with complex or chronic conditions, including care planning, disease education, symptom monitoring, goal setting, and self-management support.
- Work closely with primary-care providers, care teams, pharmacists, specialists, hospitals, home health agencies, and community partners to ensure coordinated, patient-centered care.
- Recognize changes in patient condition, respond to urgent clinical needs, and facilitate appropriate follow-up or escalation of care.
- Document care-management services, patient outreach, clinical assessments, education, and coordination activities in the electronic health record in accordance with organizational, ACO, payer, and CMS requirements.
Population Health & Performance Improvement
- Engage in network quality initiatives aimed at reducing readmissions, improving medication adherence, and enhancing patient outcomes.
- Use data analytics to identify at-risk patients and develop targeted outreach strategies.
- Participate in cross-functional meetings to drive operational improvements.
Controlled Substance Stewardship
- Participate in the implementation of network-wide controlled substance monitoring protocols, collaborating with providers to ensure compliance and safety.
- Review patient histories for risk, support utilization of prescription drug monitoring programs, and provide education on safe use, storage, and disposal.
Core Competencies
- Patient centered communication and coordination.
- Strong communication and patient education skills.
- Proactive problem-solving and time management.
- Data review and documentation accuracy.
- Flexibility and adaptability in a team-based environment.
- Commitment to patient safety, satisfaction, and value-driven care.
Other Responsibilities
- Provide care coordination through regular phone and electronic outreach, EHR review, and virtual team meetings.
- Perform all other duties as assigned by the supervisor and/or designee.
Requirements
Education & Experience
- Registered Nurse (RN) with active state licensure; BSN preferred.?
- Minimum of 3 years’ experience in primary care, case management, or population health settings.?
- Skilled in telephonic and virtual patient communication, clinical assessment, and coordination across settings.
- Proficient in using EHRs, and population health analytics tools.
- Familiarity with CMS Care Coordination Services standards and guidelines preferred.
- Ability to collaborate effectively communicate across multidisciplinary and multisite teams.
