Care coordinator - Clinical Care Team

Care Coordinator - Clinical Care Team

Job Title: Clinical Care Team Care Coordinator



Location: Hybrid | Altamont, TN



Contract: Long-Term Contract



Schedule: Monday Friday, 8:00 AM 4:30 PM CST



Bill Rate: $ 22 Per Hour

Residency: Tennessee residents only

Position Highlights

• Support patients with social needs, care coordination, and access to community resources .

• Coordinate referrals, follow-up care, medical records, and patient assistance programs.

• Work closely with primary care providers, nurses, social workers, hospitals, and community partners .

• Help identify and address barriers that may prevent patients from accessing healthcare and social services.

• Participate in community outreach and healthcare coordination activities.

Responsibilities

• Conduct social needs screening and provide navigation support for food, housing, transportation, mental health, and other community resources .

• Maintain resource information, including eligibility requirements, referral procedures, costs, and contact details.

• Coordinate case management activities, including hospital discharge follow-up, care plans, medical records, and medical equipment needs.

• Assist with specialty referrals by scheduling, coordinating, tracking appointments, and obtaining required records.

• Help patients access affordable prescription options, including patient assistance programs and other available resources.

• Document patient interactions, referrals, care coordination activities, and follow-up in the patient record.

• Provide patient education and connect patients with appropriate educational resources.

• Collaborate with healthcare providers, nurses, social workers, regional teams, and community organizations.

• Participate in clinical meetings, provider meetings, Health Councils, and community outreach activities.

• Identify barriers to care and support appropriate solutions.

Requirements

• Experience in healthcare, care coordination, case management, social services, patient navigation, or a related field .

• Experience working with patients and connecting individuals with community or healthcare resources.

• Knowledge of social determinants of health (SDOH) and community-based services.

• Strong organizational skills with the ability to manage multiple referrals, follow-ups, and patient needs.

• Experience documenting patient interactions and care coordination activities in electronic systems.

• Strong communication, interpersonal, and problem-solving skills.

• Ability to collaborate effectively with clinical teams, social workers, providers, and community partners.

• Ability to maintain confidentiality and handle patient information appropriately.

• Ability to work independently and as part of a multidisciplinary healthcare team.

• Valid driver's license and access to reliable transportation for required travel.

Preferred Qualifications

• Experience in primary care or public health settings.

• Experience with case management or patient navigation.

• Experience with hospital discharge planning and specialty referral coordination.

• Familiarity with prescription assistance programs and healthcare coverage resources.

• Experience working with community organizations and social service agencies.

This position supports patient care coordination and community resource navigation while helping improve access to healthcare and social services.