About the role
Position: RN Care Coordinator / Clinical Care Coordinator
Location: Portland, Oregon (Multnomah, Clackamas, Washington, and Yamhill Counties)
Duration: 6-12 Months Contract
Schedule: Monday-Friday, 8:00 AM-5:00 PM
Program: ISNP (Institutional Special Needs Plan)
Travel: Required between multiple long-term care and skilled nursing facilities during work hours
Position Summary
We are seeking a compassionate and experienced Registered Nurse (RN) Care Coordinator to support the ISNP program. This role will partner closely with providers, advanced practice clinicians (APCs), facility staff, and interdisciplinary care teams to coordinate care for members residing in long-term care and skilled nursing facilities. The RN Care Coordinator will play a critical role in improving health outcomes, ensuring accurate documentation, coordinating services, and supporting quality initiatives.
Key Responsibilities
- Ensure accurate, complete, and timely clinical documentation.
- Collaborate with providers, APCs, facility staff, and interdisciplinary care teams.
- Assist with patient care coordination and transitions of care.
- Support Medicare Part A, Part B, and Part D benefit determination and coordination.
- Identify and respond to changes in patient condition alongside providers and facility staff.
- Coordinate therapy services and follow-up care.
- Participate in facility meetings, team meetings, case presentations, and family conferences.
- Assist with quality improvement initiatives, training, compliance tracking, and reporting.
- Create and conduct educational in-services for staff and care teams.
- Support providers with documentation, coding, medication reconciliation, nursing assessments, and patient care planning.
- Document verbal orders from providers in compliance with state nursing regulations and facility policies.
- Assist in managing acute medical conditions and exacerbations of chronic illnesses.
- Support members during short-term rehabilitation and post-acute care episodes.
- Maintain effective communication with patients, families, providers, and facility staff.
Required Qualifications
- Active and unrestricted Registered Nurse (RN) license in the state of residence or ability to obtain prior to start date.
- Associate Degree in Nursing (ADN) or higher.
- Current Basic Life Support (BLS) certification.
- Ability to perform physical assessments and meet physical job requirements, including lifting up to 30 lbs.
- Reliable transportation and ability to travel between facilities.
- Full COVID-19 vaccination (subject to applicable regulations and client requirements).
- Ability to pass a pre-employment drug screening.
Preferred Qualifications
- Minimum 1 year of clinical nursing experience.
- Long-Term Care (LTC), Skilled Nursing Facility (SNF), Geriatrics, Hospice, Case Management, or Managed Care experience preferred.
- Experience working with patients who have complex medical, behavioral, social, and functional needs.
- Understanding of geriatric populations and chronic disease management.
- Experience coordinating interdisciplinary care plans.
- Strong EMR/EHR documentation skills.
- Excellent communication, organization, and time-management abilities.
- Ability to work independently while collaborating with multidisciplinary teams.
Certifications Required
- Active RN License
- Basic Life Support (BLS)
- Associate Degree in Nursing (ADN) or higher
Ideal Candidate Background
- Registered Nurse with long-term care, skilled nursing, hospice, care coordination, case management, or geriatric experience.
- Comfortable traveling between multiple facilities.
- Strong documentation, assessment, and interdisciplinary collaboration skills.
- Experience supporting Medicare beneficiaries and complex care management initiatives.
Must-Have Requirements
✅ Active RN License
✅ Associate Degree in Nursing or higher
✅ Current BLS Certification
✅ Care coordination and clinical documentation skills
✅ Reliable transportation and ability to travel between facilities
✅ Experience working with complex patient populations
✅ Ability to collaborate with interdisciplinary care teams
Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.
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