Advance Primary Care Program (APCM) Coordinator

Job Overview
Windsong Primary Care is expanding our innovative Advanced Primary Care Program and seeking a skilled, patient‑centered Program Nurse to join our growing team. This role is ideal for a nurse who thrives in a collaborative environment, values proactive and preventive care, and enjoys building long‑term relationships with patients and families.

The Advanced Primary Care Program Nurse plays a key role in delivering high‑value, team‑based care. This position supports our primary care providers through comprehensive care coordination, chronic disease management, patient outreach, and proactive population‑health initiatives. You’ll help patients navigate their care, close care gaps, and improve outcomes through education, follow‑up, and personalized support.

Responsibilities

• Serve as the primary point of contact for all program-related activities, ensuring smooth communication among healthcare providers, patients, and external partners.
• Assist in developing, implementing, and monitoring program workflows to optimize patient engagement and care coordination.
• Maintain accurate documentation of patient interactions, program activities, and compliance requirements in accordance with organizational policies.
• Collaborate with multidisciplinary teams to identify patient needs and facilitate appropriate resource referrals or interventions.
• Conduct care coordination, follow‑up calls, and chronic disease management outreach
• Support preventive care initiatives, including screenings, immunizations, and care‑gap closure
• Assist with transitions of care, including hospital/ER follow‑up and medication reconciliation
• Provide patient education on disease processes, self‑management, and treatment plans

Experience

• Prior experience in healthcare coordination, case management, or program administration within a primary care health setting is preferred.
• Strong organizational skills with the ability to manage multiple tasks simultaneously while maintaining attention to detail.
• Excellent communication skills—both verbal and written—to effectively liaise with diverse stakeholders.
• Proficiency in electronic health records (EHR), or healthcare management software is desirable.
• Ability to work independently as well as part of a collaborative team in a fast-paced environment.

We Offer

A supportive, team‑oriented environment with two primary care providers and two orthopedic providers

• Opportunity to be part of an innovative, forward‑thinking care model
• Stable, community‑focused practice with long‑standing patient relationships
• Professional growth and involvement in quality and care‑management initiatives
• Generous PTO
• 401k Plan

Pay: $18.00 - $24.00 per hour

Benefits:

• 401(k)
• Paid time off

Work Location: In person