Prime Care Coordination
  • Rochester, NY, USA
  • Full Time

Monday-Friday Position.


The Registered Nurse for Prime Care Coordination (PCC) will serve as a member of the assigned regional clinical support team responsible for reviewing case specific information and consulting with care managers to ensure coordinated services are provided to indivuduals supported by PCC. The RN is also responsible for providing clinical recommendations to enhance service delivery. In partnership with the care coordination team, the RN will provide training and information to individuals and family members, to promote health and well-being, mitigate risk factors and ensure ongoing support.

Essential Job Funtions:

  • Review case specific information and consult with to care managers to ensure coordination of services
  • Provide clinical recommendations to enhance service delivery
  • In partnership with the care coordination team, provide training and information to individuals and family members, to promote health and well-being and ensure ongoing support; 
  • Educate Care Managers, individuals and family members on diagnoses, health conditions and medications; 
  • Provide discharge planning assistance to care managers, and attend discharge conferences when appropriate, to support the care manager and family and ensure the plan is in the best interest of the individual;
  • Under the supervision of the director, monitor quality of care outcomes that contribute to overall team performance in achieving desired clinical and operational performance measures.
  • Assist care managers with the interpretation of assessments and screening tools, recommend additional screening or assessment when appropriate, and facilitate access to preventative health screenings.
  • Work in partnership with care managers, assess safety concerns in an individual's environment promote accessibility and mobility, as well as to provide instruction in patient safety
  • Conduct assessments and assist in developing Life Plans
  • Conduct clinical reviews for individual specific needs or overall program trends and outcomes
  • Conduct home visits for assessment and planning for individuals and families with complex health needs
  • Case conference with clinical providers of treatment to ensure continuity of care
  • Provide health literacy programs and traning for staff
  • Provide crisis intervention, referrals and support to individuals and families
  • Provide on call availability with shared coverage with other clinical team members
  • Represent Prime Care Coordination on appropriate committees, boards, and task forces.
  • Establish and maintain positive relationships at all levels inside and outside of the organization.
  • Perform all other duties relevant to the position as requested.

Knowledge, Skills, and Abilities

  • Knowledge of OPWDD and/or DOH program and service delivery system.
  • Must be able to multi-task, establish priorities, and meet deadlines.
  • Ability to work in a collaborative environment, work independently and motivate others.
  • Ability to communicate effectively, both orally and in writing.
  • Ability to act quickly, assess and act accordingly in crisis situations.
  • Basic technology skills and understanding of health records. 
  • Maintain appropriate confidentiality and discretion at all times. 

Education and Experience

  • Must be licensed and currently registered as a Registered Nurse by the New York State Education Department; BSN preferred.
  • Specialized traning or one year of professional experience in working with individuals with intellectual and/or developmental disabilities. 
Prime Care Coordination
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