The Care Coordinator RN works to eliminate barriers to care for (primarily) high risk patients and prevent avoidable readmissions. He/she works as part of an integrated team with Population Health, Care Coordination, Providers, Clinic Administrators, Health Information Management Program Manager, and Billing to ensure smooth continuum of care for identified patients. This includes managing a panel of high risk patients to ensure they are maximizing the resources available to them, making referrals and follow-up appointments, making telephone calls to patients, assisting patients in making and attending scheduled appointments, assessing patients to coordinate care with other healthcare providers, working with other healthcare providers to transition care as needed, and directing inquiries. The Care Coordinator RN may also conduct in-home or hospital visits to high risk patients to support successful transitions back into the home and to prevent readmissions or avoidable ER usage.