Why Crouse Medical Practice? At Crouse Medical Practice, our focus is on improving the lives of our patients. This focus is what drives us to recruit the best employees to support our patients. Our practice fosters an inclusive environment that prioritizes work-life balance, welcoming individuals from all backgrounds to join our close-knit work family. Come join our work family!! Heres what we offer: Monday-Friday work week Supportive team environment Competitive starting rates based on experience Annual salary increases Opportunities for professional growth stability within a fast-growing Medical Practice Longevity and consistency of management Perfect attendance award Tuition reimbursement program Employee referral program Affiliation with Crouse Hospital Other benefits include: Generous Health/Dental/Vision Life insurance, Flexible spending account or Health savings account available first of the month following your date of hire, Employee assistance program,15 days of paid time-off within first year of employment, 7 paid holidays annually, and a 401k with 4% employer match. Position Description: The RN Care Coordinator CCM serves as a proactive patient advocate, educator, and care manager for Medicare beneficiaries enrolled in Chronic Care Management services. This role is grounded in a team-based, patient-centered approach that prioritizes relationship-building, early intervention, and coordination across the care continuum. The RN uses clinical knowledge and care coordination skills to empower patients to manage chronic conditions effectively, reduce unnecessary utilization, and improve quality of life. Responsibilities: Serve as the primary point of contact and trusted health advocate for an assigned caseload of Medicare patients with two or more chronic conditions. Build long-term rapport through monthly outreach calls and routine communication Conduct thorough assessments of physical, emotional, social, and environmental needs. Develop and regularly update a comprehensive, patient-centered care plan with measurable goals and interventions, documented in the EMR. Promote self-management and health literacy through coaching, education, and collaborative goal setting. Coordinate internal and external services including primary care, specialty care, behavioral health, pharmacy, social services, and community resources. Prevent avoidable hospitalizations and ER visits through timely follow-up, medication review, and problem-solving interventions. Support transitions of care by ensuring communication, scheduling follow-ups, and medication reconciliation. Document all interactions, assessments, and updates per CMS billing requirements. Actively participate in team huddles, staff meetings, and improvement initiatives. Maintain productivity standards and contribute to department-wide billable goals. Assist in supporting new team members and sharing best practices. Enroll new patients into the CCM program and assess eligibility based on insurance, history, and risk-level. Minimum Qualifications: Current RN licensure in New York State. Associates Degree in Nursing; BSN preferred. Strong interpersonal communication and motivational interviewing skills. Demonstrated understanding of chronic conditions, medication management, and preventative health. Experience in case management, population health, or care coordination preferred. Familiarity with EMR systems and Microsoft Office. Commitment to cultural humility and sensitivity to diverse populations. Pay Range: $58,000.00 - $72,000.00DOE