Care Coordinator II

How Will You Make An Impact

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.
• 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:
• Chronic disease management
• Medication adherence
• Preventive health measures
• Self-management strategies
• Community resources and support programs
• Refer to ACO pharm to assist with PAP

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 management, transitional care, home health, or related setting preferred.
• Experience working with chronic disease management and high-risk patient populations preferred.
• Experience with electronic health records (EHR) required.
• Knowledge, Skills, And Abilities
• 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.
• Reporting Relationship
• Reports directly to the RN Care Manager and works collaboratively with physicians, advanced practice providers, care managers, case managers, social workers, and other members of the healthcare team.
• Work Environment
• This position is primarily based remotely, may be in an MPG main office and/or a an outpatient clinic, and involves telephonic patient outreach, care coordination activities, and occasional interaction with community agencies and healthcare facilities.