Nurse Care Coordinator

HWP is focused on providing chronic care management (CCM), Remote Patient Monitoring (RPM), and Transitional Care Management (TCM) services to patients through our novel service offering.  HWP services patients independently through direct referrals and also through agreements with other providers as an outsourced clinical vendor.

Under the direction of our Nurse Practitoner/ Clinical Practice Leader- The Nurse Clinical Care Coordinator is the face of HWP to our patients.  Through specific patient and care team contacts, you will act to enable patients and their care teams by helping coordinate management of the patient’s underlying disease states.  The Nurse Clinical Care Coordinator is a patient facing role that will deliver care directly to patients and their caregivers and supervise CNAs, MAs, and unlicensed staff in their clinical interaction with patients.

This position offers the flexibility of a hybrid work environment.  Standard hours are Monday-Friday 830am-5pm.

What You’ll Do

·        Provides ongoing care coordination and patient navigation for patients over the phone and other non-face to face modalities.

·        Work directly with our Clinical Practice Leader to onboard patients by obtaining past medical history and clinical information.

·        Create care plans for review and sign off by our Clinical Practice Leader  

·        Functions as a liaison between patients and their care team to improve communication and patient care.

·        Coordinates medical care for patients, including patient education, program enrollment, appointment management, coordination of on-going diagnostics, medication adherence and adverse effect monitoring, and provider communication. 

·        Work with our MAs/CNAs/ non-licensed staff by directing them on best practices to resolve a patient’s clinical issues including assessing appropriate escalation pathways for concerns as necessary.

·        Communicates with the HWP Clinical Practice Leader and healthcare providers as appropriate to ensure timely communication about patient care and concerns. 

·        Initiates, monitors and coordinates care planning for assigned patients, including coordination with the patient’s pharmacy on timely medication delivery .

·        Places and receives high volumes of patient calls daily, while remaining organized and diligent with any identified follow up tasks.  

·        Documents CCM care plans in the CCM Software and EMR, coordinates relevant follow up and communicates with providers and supervisors as needed. Care plans should be worked on daily and daily/weekly goals will be provided.

·        Prepares documentation for billing purposes for the Chronic Care Management (CCM) program. 

·        Achieves monthly goals for billed coordination services or provides real time feedback into why goals were not achieved. 

·        Provides a significant amount of patient/family education regarding the patient’s disease states including proper monitoring and care

·        Communicates in a caring and professional manner with patients, staff, and physicians. 

·        Actively advocates for patients to improve their healthcare experience and treatment outcomes. 

·        Other duties as assigned. 

·        Partner with the patient’s care team to drive clinical outcomes including reducing admissions and hospitalizations

·        Participate in continuing quality improvement activities for all staff including identifying and resolving opportunities for staff education and process improvements

·        Demonstrate excellent interpersonal skills to relate to healthcare personnel, proven success in working cooperatively and collaboratively to resolve problems, as well as effectively communicating within and outside of the department.

What You’ll Need to Succeed

·        Current, valid MA Licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN)

·        Willingness to acquire other state licenses, as required by business need

·        2 years' experience in a primary care/internal medicine role working with patients with chronic disease states

·        Creativity to drive enhanced service offering to patients by providing high quality care and care team enablement

·        Experience with delivering care to patients virtually preferred

Make A Difference With HWP

HWP is a new approach to care management and care team enablement.  Working directly with the patient’s pharmacy and care team, we fill the gaps in a patient’s care by providing high quality virtual health care services for chronic disease states with a team of clinicians.  With a focus on medication management and a built-in relationship with a pharmacy partner, we work with our patients to offer advice on how to live best with their chronic disease states and, through objective and subjective data collection, detect issues before they lead to bigger concerns. 

We prioritize the health and well-being of our team members at HWP.  We offer medical, pharmacy, dental, and vision insurance plans, ensuring that our employees and their families have access to quality healthcare services to maintain their overall health and wellness. We offer a 401(k) plan with a generous company match, empowering our employees to save for retirement. We understand that life is full of unexpected twists, which is why we offer employer covered comprehensive short- and long-term disability and life insurance.  We also offer 10 company holidays and have a generous paid time off policy to support work life balance.  Our quarterly and end of year employee core value awards during company sponsored events uses recognition to foster a positive work culture.  Additional benefits include an employee assistance program, voluntary life, AD&D and accident coverage for employees, spouse and child, identity theft detection coverage, employee referral program and educational reimbursement.

AWP is an Equal Opportunity Employer.  AWP does not discriminate on the basis of race, creed, color, religion, national origin, sex, sexual orientation, gender identity, age, physical or mental disability, or any other basis covered by appropriate law.  All employment decisions are made on the basis of qualifications, merit, and business need. AWP is committed to providing reasonable accommodations for qualified individuals with physical and mental disabilities in our job application procedures. If you need assistance or an accommodation due to a disability, you may contact us at    We will make a determination on your request for reasonable accommodation on a case-by-case basis.