Care Coordinator

Job Description Summary

The Care Coordinator works under the direction of the RN Care Manager and in collaboration with primary care providers, patients, caregivers, and interdisciplinary team members to support care management activities in the outpatient setting. This role assists with care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, and documentation to improve patient outcomes, reduce avoidable utilization, and enhance the patient experience.
The Care Coordinator may be a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience.
Program Goals
The Care Coordinator supports the following organizational goals:

Program Goals

1. Prevent unnecessary emergency department visits and hospital admissions.
2. Reduce 30-day hospital readmissions.
3. Improve communication and care coordination between Primary Care Providers (PCPs), specialists, and acute care settings.
4. Facilitate safe and effective transitions of care.
5. Support advance care planning discussions and documentation.
6. Assist patients and caregivers in identifying the most appropriate level of care following discharge.
7. Improve patient engagement, self-management, and adherence to care plans.

Essential Responsibilities

Care Coordination

• Assist the RN Care Manager in implementing and monitoring individualized patient care plans.
• Perform monthly patient chart reviews to identify care gaps, preventive care needs, and opportunities for intervention.
• Monitor and track follow-up appointments, referrals, diagnostic testing, and care plan goals.
• Coordinate services among primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community organizations.
• Collaborate with the healthcare team to ensure continuity of care across settings.

Patient Outreach and Engagement

• Conduct telephonic outreach to patients and caregivers as directed by the RN Care Manager.
• Assess barriers to care, including transportation, medication access, financial concerns, health literacy, and social determinants of health.
• Encourage patient participation in care plans, preventive services, and chronic disease management programs.
• Build and maintain trusting relationships with assigned patients and caregivers.

Transitions of Care

• Support transition-of-care activities following emergency department visits, hospitalizations, and skilled nursing facility stays.
• Assist with post-discharge follow-up, appointment scheduling, medication reconciliation support, and identification of ongoing care needs.
• Ensure necessary services, equipment, and community resources are coordinated prior to or following discharge.
• Communicate pertinent information to providers and care team members to facilitate timely interventions.

Patient Education

• Reinforce education provided by the RN Care Manager and providers regarding:
• Chronic disease management
• Medication adherence
• Preventive health measures
• Self-management strategies
• Community resources and support programs
• Provide information on prescription assistance programs, transportation services, community resources, and support groups as appropriate. Refer to ACO pharm to assist with PAP

Clinical Documentation and Record Management

• Maintain accurate, timely, and complete documentation within the electronic health record (EHR).
• Obtain and upload medical records, discharge summaries, consult notes, and test results from hospitals, specialists, skilled nursing facilities, and other providers.
• Track care management activities, outreach attempts, patient outcomes, and quality metrics.

Resource Coordination and Advocacy

• Assist patients in accessing appropriate clinical, social, behavioral health, and community-based services.
• Maintain knowledge of local, state, and federal community resources.
• Advocate for patient needs and promote patient-centered care.
• Escalate clinical concerns to the RN Care Manager or provider as appropriate.

Qualifications

Education

• Current Florida Licensed Practical Nurse (LPN) license; or
• Certified Medical Assistant (CMA/RMA) or equivalent Medical Assistant certification from an accredited program(Preferred).

Licensure/Certification

• LPN applicants must possess an active, unrestricted Florida LPN license.
• Medical Assistant applicants must maintain current certification, if applicable.
• Current BLS certification preferred.

Experience

• Minimum of three (3) years of clinical healthcare experience in a physician practice, outpatient clinic, population health, care management, case management, transitional care, home health, or related setting preferred.
• Experience working with chronic disease management and high-risk patient populations preferred.
• Experience with electronic health records (EHR) required.

Knowledge, Skills, and Abilities

• Strong organizational and time-management skills.
• Excellent verbal and written communication skills.
• Ability to build rapport and effectively engage patients and caregivers.
• Knowledge of care coordination principles, transitions of care, and population health management.
• Understanding of chronic disease management and preventive care strategies.
• Ability to identify barriers to care and coordinate appropriate interventions.
• Strong documentation and computer skills.
• Ability to work independently while maintaining close collaboration with the RN Care Manager and interdisciplinary care team.
• Bilingual skills are a plus.

Reporting Relationship

Reports directly to the RN Care Manager and works collaboratively with physicians, advanced practice providers, care managers, case managers, social workers, and other members of the healthcare team.

Work Environment

This position is primarily based remotely, may be in an MPG main office and/or a an outpatient clinic, and involves telephonic patient outreach, care coordination activities, and occasional interaction with community agencies and healthcare facilities.

Compensation Range

$19.00

to

$28.50

The anticipated base salary range represents the Company’s good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.