Rural Care Coordinator (RN)

The RN Rural Care Coordinator owns the daily bed evaluation and capabilities of the Mercy One Central Iowa rural facilities for transfer back capacity. This includes evaluation from both clinical and payor perspectives of patients for determination of “ready-to-move” status for patients identified to move back to their home facility. Works collaboratively with physicians, staff, and other health care professionals/agencies to negotiate care coordination across the health care continuum.  Owns the communication loop with referring and receiving providers, addressing any service concerns with the movement of patients at specific intervals to enhance a holistic approach to patient care. Is accountable for Care Coordination evaluation including: data capture and analysis, outcome achievement, and fiscal responsibility in an effort to improve service, quality and cost provided to the clients served. Understands and complies with standard workflows upholding accreditation level standards.

Essential Position Expectations:

  1. Evaluates, processes, tracks, documents, and coordinates patient transfers back to MercyOne Central Iowa rural facilities from another acute location.
  2. Establish point of communication between organizations during time of transfer for referring and receiving providers and care management team.
  3. Educates staff, clients/families, and medical community on care coordination and regulatory issues that impact care and outcomes.
  4. Monitors level of care issues by aligning individual needs with appropriate or available resources maximizing benefit coverage.
  5. Applies established utilization care guidelines/criteria maintaining compliance and stewardship of resources to enhance outcomes.
  6. Delegates to support team as appropriate.
  7. Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.
  8. Has a working knowledge of financial and reimbursement processes related to Tax Equity and Fiscal Responsibility Act (TEFRA) and Medicare DRG payment, Case Rates, Managed Care Risk Contracting, etc
  9. Participates in quality improvement, measurement, and data collection to include populations with clinical and financial risk.
  10. Understands accountability for results and self-manages to support level success goals in the areas of quality, cost of care and patient experience.
  11. Upholds and supports standard workflows and procedures at accreditation level quality.
  12. Communicates with MercyOne Central Iowa rural facilities on medical readiness of patients for transfer back to the rural site for remainder of medically appropriate acute hospitalization.


Knowledge & Skills:

  1. Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.
  2. Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.
  3. Demonstrated capacity to problem solve and prioritize in complex situations.
  4. Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist. Specific knowledge regarding pathophysiology, natural history of disease processes, and impact on functional ability and level of care.
  5. Strong self-motivation and ability to work independently without direct supervision or support.
  6. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.
  7. Ability to function effectively in a team-based environment.
  8. Basic Excel and Word skills.
  9. Ability to understand and apply guidelines, policies, and procedures.
  10. Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.
  11. Proof of completion of Mandatory Reporter within three months of hire.

Mental & Physical Demands:

  1. Must be able to pass a pre-employment drug screening test at time of hire.
  2. Work onsite with regular and predictable attendance.
  3. Maneuver within the physical work environment with some bending, stooping, reaching, and light lifting.
  4. Constantly able to use hands and fingers to type, write, and file. Frequently able to use near vision for viewing computer monitor and written materials. Occasionally required to detect unusual odors that could indicate environmental issues.
  5. Use of usual and customary equipment used to perform essential functions of the position.

Minimum Requirements

Education: Graduate from an accredited school of nursing. BSN preferred.


Experience:  Minimum of 5 years previous nursing experience or 3 years and BSN in lieu of experience. Varied clinical experience preferred.


Certifications & Licenses: Iowa state licensure as a Registered Nurse. Basic Life Support required (BLS).



The above is intended to describe the general content of and requirements for this job. It is not intended to be a complete statement of duties, responsibilities, or requirements.

*COVID 19 vaccination required or qualified exemption.