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RN Care Coordinator, Full-Time Days with Rotating Weekends St Augustine FL

Flagler Health

Flagler Health

Myrtle Beach, South Carolina, US.



Healthcare Practitioners and Technical Occupations

Published on 2022-03-22 10:51

This position is located in St Augustine FL

  • Identifies patients at risk of deterioration by utilizing various tools, including LACE, Registry, etc.
  • Assesses the patient’s readiness to learn and the patient’s preferred learning modality and engages the patient in
    actively learning how to self-manage their medical conditions.
  • Educates the patient and family on key components for a safe discharge, including medication reconciliation, “red flags”
    of worsening condition, importance of follow-up appointments, and adherence to the Plan of Care.
  • Works in collaboration with the Care Coordination Team to ensure seamless transition of care from all sites of care.
  • Leads the Interdisciplinary Care Coordination Team of patient care providers along the continuum of care to reconcile
    the Plan of Care and manage hand-offs, including the Pharmacist, Social Worker, Primary Care Physicians, Specialists,
    Home Healthcare Agencies, Skilled Nursing Facilities, and the acute care setting.
  • Ensures patients receive all evidence-based services in the appropriate time frame.
  • Works to remove barriers to following the Plan of Care and increase patient motivation.
  • Tracks tests and referrals to ensure patient notification and follow-up.
  • Sees patients for assessment and follow-up in the ED, hospital, outpatient settings, and home, and telephonically to
    assess their progress and revise the Plan of Care as needed.



  • 3 year(s): Clinical Acute Care



  • Associates or better in Nursing

Licenses & Certifications


  • Basic Life Support
  • Registered Nurse
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