Care Coordinator

Program Goals 

The Care Coordinator supports the following organizational goals: 

Prevent unnecessary emergency department visits and hospital admissions. 

Reduce 30-day hospital readmissions. 

Improve communication and care coordination between Primary Care Providers (PCPs), specialists, and acute care settings. 

Facilitate safe and effective transitions of care. 

Support advance care planning discussions and documentation. 

Assist patients and caregivers in identifying the most appropriate level of care following discharge. 

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.