Southern NH Health - RN Coordinator Embedded Care - Full time

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-N trauma center, Level II Special Care Nursery, and Magnet designation for nursing excellence—we offer a full spectrum of services from primary care to advanced diagnostics and specialized treatments. Our medical staff includes over 500 providers from Foundation Medical Partners, and local practices. Foundation Medical Partners, our multi-specialty group, spans 70+ practices across southern New Hampshire and northern Massachusetts, providing coordinated, patient-centered care to thousands each year.

About the Job :

As an RN Embedded Care Coordinator, you'll be at the heart of our population health strategy, managing care for complex patients within a primary care setting. You'll collaborate with interdisciplinary teams to create individualized care plans, support chronic disease self-management, and ensure smooth transitions across care settings. This role is essential in promoting patient empowerment, improving clinical outcomes, and enhancing the overall quality of care.

What You'll Do :

• Deliver the full scope of nursing care in-person, by phone, and via telehealth
• Assess, plan, implement, and evaluate individualized care plans for complex patients
• Provide education and coaching for chronic disease self-management (e.g., diabetes, COPD, CHF, asthma)
• Coordinate care across transitions, including hospital discharges and specialty referrals
• Use population health tools and EMR systems for patient tracking and pre-visit planning
• Collaborate with internal and community partners to support patient-centered care
• Participate in quality improvement initiatives and maintain professional competencies

Who You Are :

Why You'll Love Us :