Care Coordination Specialist

About the role

As a key member of an interdisciplinary, value-based care delivery model, you will collaborate with patients, nursing, physicians, advanced practitioners, caregivers, and community partners to optimize clinical, quality, and financial outcomes. Provide comprehensive care coordination and interdisciplinary discharge planning processes for patients ensuring appropriate utilization of post-acute resources, reduce avoidable readmissions, and support accurate risk stratification.

Integrate clinical, social, and economic determinants of health into individualized care planning, ensuring alignment with patient acuity, developmental stage, and payer requirements. Proactively identify and address barriers impacting transitions of care, including social determinants of health (SDOH), to enhance patient outcomes and support appropriate risk adjustment and reimbursement optimization.

Perform transition of care management, including timely coordination of services, facilitation of medically necessary referrals, initiating post-acute authorizations if applicable, assisting with transportation needs, and effective linkage to community-based resources to ensure continuum of care. Apply strong organizational and operational management skills to coordinate multiple high-impact workflows, supporting compliance with regulatory requirements, efficient length of stay management, and improved performance in value-based reimbursement models.

Responsibilities

• Collaborate with interdisciplinary teams to optimize clinical, quality, and financial outcomes.
• Provide comprehensive care coordination and discharge planning to ensure appropriate post-acute resource utilization and reduce avoidable readmissions.
• Integrate clinical, social, and economic determinants of health into individualized care plans.
• Proactively identify and address barriers impacting transitions of care, including social determinants of health (SDOH).
• Perform transition of care management, including coordination of services, referrals, post-acute authorizations, transportation, and linkage to community resources.
• Apply organizational and operational management skills to support compliance, length of stay management, and value-based reimbursement performance.

Requirements

• Bachelor's degree in social work, psychology, or healthcare-related field OR High School Graduate/GED and LPN License.
• Medical Social Work or LPN experience preferred.

Schedule

Part-time, 16 hours per week. Saturday & Sunday, 8:30 AM - 5:00 PM (every weekend).

Benefits

• Health, Dental, and Vision benefits
• Paid time off
• Tuition reimbursement
• 401k match and additional yearly contribution
• Yearly performance appraisals and team award bonus
• Community discounts

Location

North Bay Hospital - New Port Richey, FL