Care Coordinator II

Job Description Summary ‎ The Care Coordinator works under the direction of the RN Care Manager and in collaboration with primary care providers, patients, caregivers, and interdisciplinary team members to support care management activities in the outpatient setting. This role assists with 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 Care Coordinator may be a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience. ‎ How will you make an impact & Requirements ‎ 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. 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. 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 identif