Clinical Coordinator III (RN) - Geriatrics Palliative Medicine

Clinical Coordinator III (RN) - Geriatrics Palliative Medicine

• Job Type: Officer of Administration
• Regular/Temporary: Regular
• Hours Per Week: 35
• Salary Range: $110,000 - $117,500

Position Summary

The Division of Geriatrics and Palliative Medicine is seeking an experienced Clinical Coordinator III (RN) to support patients receiving care through the outpatient Geriatrics and Palliative Medicine practice. The Clinical Coordinator will provide comprehensive care coordination, longitudinal case management, patient and caregiver education, transition management, and interdisciplinary care support for older adults and individuals living with serious illness.

Reporting to the Outpatient Palliative Care Medical Director and/or Division Chief, the Clinical Coordinator will collaborate closely with physicians, advanced practice providers, social workers, pharmacists, home health agencies, hospice providers, and community organizations to improve access to care, promote goal-concordant treatment, enhance patient and caregiver experience, and reduce avoidable emergency department visits and hospitalizations.

Responsibilities

Clinical Care Management

• Establish therapeutic relationships with patients, families, and caregivers.
• Provide evidence-based nursing care and care coordination consistent with best practices in geriatrics and palliative medicine.
• Conduct comprehensive patient assessments through in-person and telehealth encounters.
• Identify high-risk patients and support interventions that address complex medical, functional, psychosocial, and palliative care needs.
• Coordinate referrals, diagnostic testing, transportation services, durable medical equipment, home-based services, and insurance authorizations.
  Facilitate safe transitions across care settings, including hospital, rehabilitation, home care, and hospice.
  Monitor patient status longitudinally and proactively address barriers to care.

Patient and Family Support

• Educate patients and caregivers regarding diagnoses, treatment plans, symptom management, medications, and available resources.
• Support advance care planning, including advance directives, healthcare proxy documentation, and MOLST/POLST completion.
• Assist with hospice referrals, bereavement support resources, and end-of-life care coordination.
• Assess caregiver burden and connect caregivers with support services, respite programs, adult day services, legal resources, and community-based organizations.
• Address social determinants of health affecting access, safety, wellbeing, and treatment adherence.

Geriatric and Palliative Care Coordination

• Assist in the assessment and management of frailty, falls risk, cognitive impairment, behavioral symptoms, medication-related concerns, and functional decline.
• Coordinate services with community agencies and support programs, including aging services, transportation providers, meal programs, behavioral health services, and memory care resources.
• Promote age-friendly and person-centered care approaches across the patient population.

Clinic Operations

• Triage referrals and identify patients requiring enhanced care management support.
• Maintain an active patient registry and perform risk stratification activities.
• Conduct proactive outreach between visits to monitor patient needs and identify early signs of deterioration.
• Support medication prior authorizations, referral management, and follow-up tracking.
• Serve as a liaison between patients, families, primary care providers, specialists, and community partners.
• Participate as an active member of the interdisciplinary care team and coordinate case conferences as needed.

Quality Improvement and Performance Metrics

• Participate in quality improvement initiatives and program evaluation activities.
• Track and report key performance indicators related to:
  • Advance care planning and serious illness care.
  • Symptom assessment and management.
  • Hospice utilization and transitions of care.
  • Patient and caregiver satisfaction.
  • Caregiver burden outcomes.
  • Depression, frailty, mobility, and medication screening measures.
  • Emergency department utilization.
  • Hospital admissions and readmissions.
  • Access-to-care metrics and referral completion rates.
• Present findings and participate in divisional, clinical, and interdisciplinary meetings.

Working Relationships

The Clinical Coordinator collaborates closely with physicians, advanced practice providers, nurses, social workers, pharmacists, care coordinators, home health agencies, hospice providers, and community organizations to ensure coordinated, high-quality care for patients and families throughout the continuum of illness.

Minimum Qualifications

• Bachelor's degree in nursing or equivalent in education and experience, plus four years of related experience.
• Current New York State Registered Nurse license.
• Demonstrated ability to perform comprehensive patient assessments and coordinate care across multiple healthcare settings.
• Strong communication, documentation, organizational, and interdisciplinary collaboration skills.

Preferred Qualifications

• Minimum of three (3) years of clinical experience in Geriatrics and/or Palliative Medicine.
• Certification in Hospice and Palliative Nursing (CHPN) or equivalent certification.
• Certification in Geriatric Care Management and/or geriatric specialty training.
• Bilingual fluency in English and Spanish.
• Experience working with medically complex older adults and patients with serious illness.

Other Requirements

• Medical clearance and participation in the medical surveillance program
  • Contact with patients and/or human research subjects
  • Wear N-95 Respirator
• Successful completion of applicable compliance and systems training requirements.

Equal Opportunity Employer / Disability / Veteran

Columbia University is committed to the hiring of qualified local residents.