RN, Chronic Care Management Coordinator

Primary Care Cabot Drive

Oak Harbor, WA

Nursing

Full-time, Days 8 hour, Mon-Friday/ 8:00-4:30

FTE 1

Posted 01/27/2026

Req # 16462

Work Location: Onsite

Job Summary

The RN Chronic Care Management Coordinator is responsible for growth and maintenance of the care coordination program which includes oversight and management of patients enrolled in care management services; assurance of the completion of the annual wellness visit and follow up on all elements of the preventative plan of care; and completion of discussions of advance care planning with patients. These responsibilities will be completed by collaboration with intra and inter departmental staff of the organization, outreach, disease management/care management, care coordination/health promotion, education/training and motivational support to patients, referral sources and the community. This position will work to improve the quality of life of patients enrolled through supporting quality outcomes, smooth care transitions, coordination of care across the health continuum, encourage healthy lifestyle choices to reduce long term effects of chronic illness. This position is accountable for working with and representing our clinics across multiple constituents and for the financial performance of the program.

PRINCIPLE FUNCTIONS includes the following, other duties may be assigned:

• Exhibit competence in the Seven Domains of Care Coordination in the primary care setting:
• Population Health Management,
• Comprehensive Assessment and Care Planning,
• Interpersonal Communication,
• Education/Coaching,
• Health Insurance and Benefit knowledge,
• Community Resource knowledge and
• Research and Evaluation skills.
• Demonstrate skills in effectively coordinating and monitoring care to promote quality and cost-effective outcomes.
• Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for care coordination recruitment purposes.
• Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community.
• Assess and identify participant’s readiness, willingness, and ability to change.
• Identify patient coaching, support, and educational needs by focusing on what is important to their quality of life.
• Determine and connect with relevant community and/or health care resources to support solutions; provide educational tools to promote self-management.
• Collaborate with the patient to develop interventions and sets goals for behavioral modification within the scope of nursing practice.
• Conduct health and wellness coaching sessions to assist participants in making lasting changes to their health and wellness.
• Monitor and document the patient’s progress toward his or her optimal level of wellness.
• Promote wellness and provides education regarding preventative care measures.
• Act as a liaison between referral sources, facilities, and outside entities to prevent and/or resolve continuum of care issues
• Communicate with service delivery partners, providers, and other health professionals to provide care coordination to ensure the plan of care facilitates the efficient use of health care resources.
• Proactively follow up with patients discharged from all hospitals, rehab facilities and emergency rooms to recruit patients into the care management services to ensure patient has an appointment with their provider and reviews any unmet needs prior to the upcoming appointment.
• The RN Chronic Care Management Coordinator may be asked to perform principal functions of the RN position at a primary care clinic.
  

Job Knowledge & Qualifications

Education

• Graduate of an accredited school of nursing.
• BSN preferred.
  
  

Training And Experience

• Three (3) years’ clinical experience including working with the geriatric population preferred.
• Previous work experience with educating patients and patient goal setting preferred.
• Previous work experience in an autonomous position.
• Minimum of one (1) year recent home care experience preferred.
• Must be able to perform the essential functions of the job to serve patients of all ages.
• Knowledge/experience with Cross Tx CCM platform.
  
  

Certificates, Licenses, Registrations

• Active WA State RN License or Active Multistate License (MSL)
• MSL Requirements:
• Approved 6-Hour Suicide Prevention Training Course Completion
• Screenshot of submitted demographic data using the Washington State Multistate Nurse Demographic Data Survey.
• American Heart Association BLS required.
  

Benefit Information and Wage Transparency: WhidbeyHealth Employees who work a 0.6 FTE or higher are categorized as, “benefit eligible”.

Click here for benefit information.

Wage Range: $40 - $72

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