Care Coordinator

Job Description Summary

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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:
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:
o Chronic disease management
o Medication adherence
o Preventive health measures
o Self-management strategies
o 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
One of the following:
• 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 mana