Clinical Care Coordinator

Manages an assigned panel of Medicare beneficiaries and serves as the operational link among patients residing in assisted living facilities (ALFs), their families and caregivers, providers, facility staff, and the CareConnectMD interdisciplinary clinical team. Coordinates transitions and follow-up services, identifies and addresses barriers and gaps in care, supports implementation of individualized care plans, and ensures that patient needs are documented, communicated, and tracked through resolution or escalation.

Responsibilities

• Serves as a supportive team member to assigned providers, facility staff, and the CareConnectMD interdisciplinary clinical team.
• Assists with scheduling and coordinating regular provider visits for assigned patients.
• Conducts structured patient outreach and assessments by telephone and in assisted living communities to collect clinical, functional, and psychosocial information.
• Provides patient and family/caregiver education and support related to diagnoses, treatment plans, services, and self-management.
• Develops and maintains effective relationships with patients, families, caregivers, and facility staff to promote meaningful communication and proactively identify changes in condition or emerging needs.
• Assists clinical team members with obtaining medical records, laboratory results, imaging reports, and other relevant patient information.
• Partners with the CareConnectMD clinical team to identify and address changes in condition, care gaps, medication concerns, unmet social needs, barriers to care, and opportunities to reduce avoidable emergency department visits and hospitalizations.
• Supports implementation and follow-up of patient care plans and service needs, ensuring identified actions are communicated and tracked through resolution or escalation.
• Contributes relevant patient and care coordination insights to weekly interdisciplinary team discussions.
• Maintains accurate, timely, and complete documentation of assessments, interventions, patient responses, communications, and follow-up activities in accordance with organizational standards.
• Participates in quality assessment and performance improvement initiatives and ongoing professional development.
• Maintains patient confidentiality and complies with HIPAA, organizational policies, documentation standards, and applicable federal and state requirements.
• Other duties as assigned.

Requirements

• Current California Licensed Vocational Nurse (LVN) license.
• One (1) to three (3) years of nursing experience.
• Experience working with older adults in assisted living facilities (ALFs), long-term care, skilled nursing, or other senior care settings (strongly preferred).
• Geriatric and/or primary care experience (strongly preferred).
• Experience with long-term care or assisted living EHR/EMR systems (preferred).
• Knowledge of value-based care, care coordination, and/or Medicare populations (preferred).
• Ability to conduct independent visits to assisted living facilities throughout an assigned region; travel is required.
• Reliable transportation required for conducting patient visits.
• Employees who drive a personal or company vehicle must comply with all applicable CareConnectMD policies and requirements.
• Current CPR certification as required by organizational policy.

Skills

• Ability to coordinate services across providers, facilities, patients, caregivers, and external partners and track identified needs through resolution or appropriate escalation.
• Strong organizational and time-management skills with the ability to prioritize competing demands and manage multiple tasks efficiently.
• Ability to document clinical assessments, outreach, interventions, patient responses, communications, and follow-up activities accurately and within required timeframes.
• Strong interpersonal and communication skills, including the ability to effectively communicate with older adults, individuals with cognitive impairment, family members, caregivers, facility staff, and healthcare providers.
• Demonstrates initiative, sound judgment, adaptability, resourcefulness, and effective problem-solving skills.
• Ability to work independently while also collaborating effectively within an interdisciplinary clinical team.
• Comfortable working in a developing, fast-paced program and adapting to evolving workflows, technology, and operational requirements.
• Proficiency with electronic health records (EHR/EMR), care management systems, Microsoft Outlook, Word, Excel, virtual meeting platforms, and other clinical or administrative software.
• Strong written communication and documentation skills, including the ability to prepare clear, accurate, concise, and professional clinical notes and correspondence.

Core Competencies

• Instills trust
• Customer focus
• Manages ambiguity
• Collaborates
• Drives results

Proof of full COVID vaccination is required for employment, subject to legally recognized accommodations.