RN Embedded Care Coordinator - Foundation Collaborative Care - Full Time - Foundation Medical Partners

Come work at the best place to give and receive care!

Job Description:

Who We Are

Southern New Hampshire Health has been a cornerstone of the region since 1893, delivering high-quality, compassionate care close to home. Anchored by Southern New Hampshire Medical Center-a 188-bed, DNV-accredited hospital in downtown Nashua with a Level III Trauma Center and Level II Special Care Nursery-we are proud to be a five-time Magnet-designated organization for nursing excellence.

Our system includes over 500 providers across Foundation Medical Partners and affiliated practices. Foundation Medical Partners, our multi-specialty group, spans 70+ locations across southern New Hampshire and northern Massachusetts, delivering coordinated, patient-centered care to thousands each year.

About the Job

The RN Embedded Care Coordinator plays a critical role within a primary care practice, focusing on managing care for complex and high-risk patients. This position partners closely with providers and care teams to deliver proactive, coordinated, and patient-centered care that improves outcomes and supports patients in managing their health.

What You'll Do

• Manage a panel of complex patients, developing individualized, longitudinal care plans in collaboration with an interdisciplinary team

• Provide chronic disease education and self-management support (e.g., diabetes, COPD, CHF, asthma)

• Coordinate care across settings, including hospital discharges, specialty referrals, and pre-visit planning

• Conduct patient assessments and interventions in-person, via phone triage, and through telehealth

• Proactively manage transitions of care to reduce readmissions and improve continuity

• Utilize population health tools and EMR systems to identify and manage patients in need of care coordination

• Serve as a liaison between patients, providers, and community resources to ensure seamless care delivery

• Support quality improvement initiatives focused on patient safety, outcomes, and access to care

Who You Are / Requirements

Minimum Qualifications

• Associate's Degree in Nursing (ASN) from an accredited program

• Active Registered Nurse (RN) license in the state of New Hampshire

• Current BLS/CPR certification

• 2+ years of clinical nursing experience in a relevant specialty

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) or enrollment in a BSN program

• Experience in ambulatory care, case management, population health, or public health

• Certification in Ambulatory Care Nursing (RN-BC), Care Coordination (CCTM), or similar

Key Skills & Attributes

• Strong clinical knowledge, particularly in chronic disease management

• Excellent communication, coaching, and patient education skills

• Ability to manage a dynamic caseload of approximately 150 patients

• High emotional intelligence, organization, and adaptability

• Comfort with EMR systems and data-driven care tools

Why You'll Love Us

• Health, dental, prescription, and vision coverage for full-time & part-time employees

• Short-term and long-term disability, life, and pet insurance

• Tuition reimbursement

• Nursing Student Loan Paydown Program

• 403(b) retirement savings plan with company match

• Continuous earned time accrual

& more!

Work Shift:

Monday - Friday 8am-5pm

SolutionHealth is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.