Job Description: Care Coordinator

Care Coordinator Job Summary: Under the general supervision of the Nursing Supervisor, the Clinic Care Coordinator plays a vital role in supporting patient-centered care through coordination and communication across the clinical team. This position is responsible for determining patient eligibility for Medicare Annual Wellness Visits (AWVs), proactively contacting patients and/or caregivers to schedule appropriate appointments and performing professional nursing functions to assess wellness and preventive care needs. The Care Coordinator collaborates closely with patients’ Primary Care Providers (PCPs) to ensure appropriate clinical recommendations and care planning. Additional responsibilities include chronic disease management support, closing care gaps, and assisting with chart preparation. As the clinic transitions to a new Electronic Health Record (EHR) system, the Care Coordinator will contribute to quality assurance by ensuring that relevant information is reviewed and communicated effectively to nursing and provider teams to support optimal patient outcomes and care delivery.

Care Coordinator Shift Availability:

• Full Time

Care Coordinator Essential Accountabilities:

• Patient Coordination & Communication

  • Verify patient eligibility for Medicare Annual Wellness Visits (AWVs).

  • Contact patients and/or caregivers to schedule AWVs or other necessary follow-up appointments pertinent to patient’s continued medical care.

  • Provide detailed information to patients about what to expect during their upcoming appointments.

  • Send patients required pre-visit documents (Health Risk Assessment, medication list, and functional status form) and instruct them to complete and bring these to the appointment, if scheduled for an Annual Wellness Visit with Care Coordinator.

• Scheduling & Planning

  • Coordinate appointments between the AWV schedule and provider availability to best accommodate the patient's needs.

  • Schedule any lab appointments necessary for patient care to best accommodate patient’s needs.

  • Develop personalized prevention plans in collaboration with the patient and provider based on assessments.

• Clinical Assessment, Data & Reporting Support

  • Evaluate and assess healthcare needs based on screenings and patient history.

  • Obtain provider input as needed to determine appropriate care and clinical recommendations.

  • Assist with prescription refills, and order labs or imaging per protocol.

  • Work in collaboration with the clinic quality nurse to execute care to complete any care gaps closures identified for performance reporting and pay incentive programs.

• Documentation & Compliance

  • Document all preventive screenings, immunizations, functional needs, and recommendations in the Electronic Health Record (EHR).

  • Ensure all relevant medical information is shared with appropriate departments to support continuity of care.

  • Follow all organizational policies, procedures, and protocols to promote consistent and effective care delivery.

• Provider/ Team Collaboration

  • Coordinate with providers to ensure necessary orders and documentation for labs, screenings, and follow-ups.

  • Collaborate with interdisciplinary team members to align care plans and avoid duplication of services.

  • Participate in regular team meetings to discuss patient needs, care gaps, and follow-up actions.

  • Serve as liaison between providers, nurses, and quality to ensure workflow efficiency.

• Additional Duties

  • Carry out other responsibilities as directed by the Nursing Director.

Care Coordinator Knowledge/ Skills/ Abilities:

• Strong interpersonal skills with the ability to build trust and rapport with patients, staff, and providers.

• Must operate with cultural sensitivity with respect to working with patients and groups of diverse racial, ethnic, economic, and social backgrounds.

• Proficient in managing multiple tasks, prioritizing work, and meeting deadlines in a dynamic environment.

• Ability to work with confidential information.

• Seeks out available resources to resolve problems.

• Possess strong verbal and written communication skills.

• Knowledge of clinical documentation practices and healthcare quality metrics.

• Ability to work independently and collaboratively as part of an interdisciplinary team.

• Proficiency in electronic health records and general computer applications (Word, Excel, Outlook).

Care Coordinator Qualifications:

Education:

• Minimum Required: Licensed Practice Nurse (LPN)

• Preferred: Registered Nurse (RN)

Experience:

• At least 2 years in healthcare or clinical coordination role, preferably involving quality or population health.

Licensure/Certification:

• Current CPR certification or ability to obtain within six months of hire.

Environmental Surroundings:

• Indoor clinical and office setting with periodic exposure to noise, temperature variations, and clinical equipment.

Physical Working Conditions:

• Must be able to sit, stand, walk, lift, and carry items weighing 20-50 pounds.

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability, status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.