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About the Role

The Care Coordinator supports care management activities in an outpatient setting under the direction of an RN Care Manager. This role focuses on 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 ideal candidate may be an LPN or an experienced MA with strong clinical knowledge and care coordination experience.

Responsibilities

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.
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.
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.
Reinforce education provided by the RN Care Manager and providers regarding chronic disease management, medication adherence, preventive health measures, self-management strategies, and community resources/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.
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.
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.

Requirements

Experience with electronic health records (EHR) required.

Skills

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.

Location

Remote
MPG main office
Outpatient clinic

Work Type

Remote
Full-time

Experience Level

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.

Education Level

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

Salary/Compensations

$19.00 to $28.50