Nursing Care Coordinator

16 Nov 2018
End of advertisement period
16 Jan 2019
Contract Type
Full Time

Position Focus: 

This position will be responsible for collaborating directly with practice providers, nurses, and support staff as well as community agencies to create consistent and coordinated delivery of high quality patient-centered health care services. Nursing actions will be directed toward the goals of prevention, assessment, risk reduction, and health status improvement. Nursing activities include, but are not limited to, systematic analysis of health data, care plan development, health education and advocacy, and collaborating with system and community partners to promote the health of a population of patients in the practice. The care coordinator will work from within the context of a patient-centered, team approach, and in continuous partnership with families and physicians to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of patient and family well-being. This position will coordinate a wide range of self-management support and disease registry activities. Success will be measured by process and outcome performance measures for the YIMA patient population.

Essential Duties 

  1. Demonstrate and apply knowledge of the philosophy/principles of comprehensive, community based, patient-centered, developmentally appropriate, culturally sensitive care coordination services.
  2. Engage patients, families and caregivers in understanding, setting and monitoring patient self-management care plans in a manner that is culturally and linguistically appropriate to the patient and caregiver.
  3. Provide care coordination, case management, referral and follow-up to individuals and families who are members of a vulnerable population and/or high-risk groups. Evaluate outcomes, effectiveness of plan, and makes changes as necessary on micro and macro levels.
  4. Proactively manage patients during transitions of care, including patients’ transitions from the Emergency department, hospital, or skilled nursing facility to home 
  5. Engage individuals and families in a plan of care that addresses their identified health deficits and issues. Provide education and counseling to individuals, family members and caregivers.
  6. Collaborate in development and delivery of programs and activities for individuals, families and population groups that promote health and prevent disease, including identifying and addressing gaps in preventative care
  7. Collaborate in the development of and contribute to individual, team, and department quality improvement and evaluation activities that support the medical home.
  8. Prepare for (pre-visit planning), attend and actively participate in team huddles, the disease registries and payer-supplied data, participate in the analysis of data to identify trends, health problems, environmental health hazards, and social and economic conditions that adversely affect patients’ health.
  9. Perform general RN duties as required by the practice, including, but not limited to the following:
  10. Demonstrate expert practice skills that include flexibility, priority setting, problems- solving, conflict resolution, negotiating and networking skills, decision-making, work delegation and organization, and verbal/written communication skills.
  11. Maintain confidentiality of patient, personnel, and institutional information.
  12. Demonstrate sound knowledge bases and actions in the decision-making process for designated patient populations.
  13. Work independently to assess and evaluate understanding of disease process, treatment plan and/or lifestyle changes.
  14. Apply professional nursing skills in the provision of preventive health maintenance and/or treatment of illness.
  15. Facilitate interdisciplinary communication among all providers and staff. 
  16. Accurately and legibly document all patient interactions in the patient record.
  17. Demonstrate self-directed learning needs and seeks ways to meet own professional development.
  18. Assess learning needs of patient and significant other to support the patient through the care continuum.
  19. Provide general patient assessments.
  20. May perform other duties assigned. 

Required Education and Experience

Bachelor’s Degree in Nursing and three years of experience or an equivalent combination of education and experience.

Required Skill/Ability 1:

Excellent oral and written communication skills.

Physical Requirements

Physical Requirements:

Preferred Licenses or Certifications:

Licensed as a Registered Nurse in the State of CT.

Background Check Requirements 

All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. All offers are contingent upon the successful completion of the background check. Please visit for additional information on the background check requirements and process.

Posting Disclaimer

The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the particular position. Employees will be assigned specific job-related duties through their hiring departments.

Yale University considers applicants for employment without regard to, and does not discriminate on the basis of, an individual’s sex, race, color, religion, age, disability, status as a veteran, or national or ethnic origin; nor does Yale discriminate on the basis of sexual orientation or gender identity or expression. Title IX of the Education Amendments of 1972 protects people from sex discrimination in educational programs and activities at institutions that receive federal financial assistance. Questions regarding Title IX may be referred to the University’s Title IX Coordinator, at, or to the U.S. Department of Education, Office for Civil Rights, 8th Floor, Five Post Office Square, Boston MA 02109-3921. Telephone: 617.289.0111, Fax: 617.289.0150, TDD: 800.877.8339, or Email: