Rural Clinical Coordinator

Job Description

Job Title

Clinical Coordinator Rural Health

Reports To

Director of TOC

Location

HV North/Hybrid

FLSA Status

Exempt

Salary Range

$77,768.60/year - $100,828.00/year

Position Summary

The Rural Health Clinical Coordinator supports the coordination and delivery of timely, appropriate, and cost-effective care for patients residing in rural communities. This position works across transitions of care, high-risk care management, and care coordination to reduce avoidable emergency department visits, hospitalizations, readmissions, and gaps in care.

The Clinical Coordinator leads proactive, team-based care for patients who are at high risk for readmissions, emergency department use, or fragmented care. This role coordinates transitions of care (TOC), delivers high-touch care management, and conducts reviews to ensure continuity of care, appropriate level of care, and cost-effective service use across the continuum.

• Identify patients in Dutchess County with high needs and/or high utilization
• Develop and support ongoing partnerships with hospital discharge planning to ensure smooth coordination for transitions of care
• Engage and support patients with high needs/high utilization to appropriate levels of care and increase utilization of primary care
• Develop and utilize appropriate protocols focused on complex care including CHF, DM, CVD, SUD and BH
• Coordinate longitudinal care for patients with complex chronic conditions across primary care, specialty, hospital, home-health, and community-service settings, with a special focus on rural regions of the Sun River Health network.
• Conduct structured patient outreach after emergency department visits and hospital discharges to evaluate symptoms, medication access, follow-up needs, and barriers to care.
• Identify discharges from inpatient, SNF, ED, and behavioral health settings within 24-48 hours of discharge notification.
• Use established clinical protocols to identify red-flag symptoms and promptly escalate concerning findings to the RN, provider, or emergency services as appropriate.
• Reinforce individualized self-management education for chronic conditions.
• Coordinate warm handoffs to community resources (home health, DME, transportation, social services) and ensure information transfer to the care team
• Maintain a defined panel of high-risk patients (e.g., multiple chronic conditions, recent hospitalizations, SDOH barriers) and stratify risk using EHR/registry data.
• Develop individualized care plans with goals, self-management support, and escalation pathways; engage patients/caregivers using motivational interviewing and health coaching.
• Coordinate multidisciplinary huddles with PCPs, specialists, behavioral health, pharmacy, and social work to address complex needs and avoid avoidable utilization.
• Document care management encounters and outcomes in the EHR/care management platform

Qualifications

• Current, unencumbered Licensed Practical Nurse (LPN) license in the State of New York.
• Proficiency with electronic health records and standard office productivity tools; comfort with telehealth technology and secure remote communication.
• Strong clinical assessment, critical thinking, and prioritization skills in a remote, high-volume environment.
• Excellent verbal and written communication skills; ability to build rapport with patients and cross-site teams in person, by phone, and video.
• Cultural humility and experience serving diverse, underserved, and rural communities preferred.
• Bilingual (English/Spanish) preferred.
• CPR/BLS certification current.

Responsibilities

Relation to Mission
The mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.

Job Responsibilities
The following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of the position. Sun River Health may change the specific job duties with or without prior notice based on the needs of the organization.