RN Care Coordinator – Lincoln

Position Location: Lincoln

Hours: Full time – 40 hours, Monday – Friday, 7:30 am – 4:00 pm

Summary: Assist in the overall management of patients, particularly those with chronic conditions.


  • Provides care coordination to patients with chronic health conditions, special care populations (i.e. substance use disorder, homeless, diabetic, COPD, CHF, prenatal etc.) or at-risk populations for increased hospitalization or emergency room utilization.
  • Consults with the patient’s primary care provider in coordinating plans of treatment and advocating for patients when necessary.
  • Establishes a self-management plan that is mutually agreed upon by the health care team and the patient/family.
  • Monitors and evaluates the progress of the patient in meeting established care goals.
  • Makes referrals on patient’s behalf and follows up to ensure that services are in place and patient’s needs are met, and follow up with patients who have not kept important referrals / appointments.
  • Identifies and effectively utilizes community resources to meet the needs of patients/families.
  • Serves as a liaison to providers, patients and families for coordination of services.
  • Works closely with HAN’s Patient Assistance Specialist to identify patients with psychosocial economic gaps.
  • Utilizes reports to identify gaps in care and patients not accomplishing goals set forth. Goals are specified in the Maine PCMH pilot and CCPM ACO.
  • Assists other members of the care team with pre-visit planning.
  • Performs initial and periodic holistic assessments for patients with chronic disease.  Prioritizes patients according to intensity, need and required follow up.
  • Performs wound care, if qualified.
  • Performs individual or group based education, counseling, or self-management goal setting.
  • Reviews self-monitoring results and incorporates them into the medical record.
  • Provides training to patients on correct use of insulin, inhalers, etc.
  • Participates in regular team meetings and peer review activities, and departmental and committees.
  • Participates in ongoing education in the field of care coordination.
  • Works effectively to provide a team-based approach in order to provide patients with quality care.
  • Performs other duties as requested.


  • Nursing degree required
  • State of Maine RN license required
  • Experience in community or home health preferred
  • Must possess sound knowledge of nursing principles, procedures, and standards of practice as determined by state and federal regulations
  • Must be able to communicate articulately and comprehend written and verbal communications

RESPONSIBLE TO: Chief Medical Officer

Interested candidates click here to complete our online employment application and submit a resume.

POST DATE: 2/23/2022

Making a difference in the lives of our patients and our community.

Providing compassionate, high quality healthcare services for all.