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

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!