Care Coordinator Transitional Program

This position operates within the transitional practice at Upper Chesapeake Health.  The Care Coordinators oversee coordination of care activities and promote population health management by breaking down barriers and providing community and health resources to the patient in a primary care setting. The Care Coordinator plays an integral part of the Care Transition patient care team and works cooperatively with the practice managers physicians and the care team to best serve the needs of the identified patient panel and primary care teams. This role helps patients navigate the healthcare system and serve as a resource specialist.

1. Assists patient and families and identify social medical and financial needs and barriers. Continues outreach through frequent contact and communication with the care team patient and family through telephone calls office visits and conducting home visits.

1. Manages resources for assigned patients by: developing relationships with the patient as an integral member of the team and providing follow-up contact with patient as indicated to ensure compliance with recommendations specialist visits Primary Care Provider (PCP) visits community resources and lab/x-ray.

1. Schedules appointments and performs reminders (via telephone calls home visits and visits to other community-based organizations as appropriate) to ensure appropriate resources are available to attend appointments. 

1. Manages main aspects of the patients care to include referrals to specialists hospitalizations ER visits ancillary testing and other services.

1. Anticipates the needs of the patient population ensuring the necessary documentation and pre-visit planning is completed or requested before patient visits.

1. Leverages local agencies throughout the community to assist our patients with getting the services they need (i.e. Mental Health Providers Specialists Radiology Services Insurance Carriers etc.).

1. Works to prevent unnecessary emergency visits and hospital admissions by communicating with local hospitals to obtain medical discharge summaries.  Collaborates with RN care managers and providers for medication reconciliation and Hospital follow-up appointments.

1. Collaborates with primary office and case manager to develop a plan of care to reduce hospital visits.

1. Assists patients in addressing challenges to care such as transportation insurance housing food and other community resources according to primary care provider to include attaining or completing applications for such services.

1. Collaborates regularly with case managers to identify rising risk patients and patient situations that require intervention.

1. Maintain professional development best practices and continuing education per department requirements.  Stay up-to-date on population health guidelines and initiatives by participation relevant educational programs and in-services.

1. Participates in departmental initiatives and process improvement plans in an effort to maximize annual departmental goals. 

1. Adheres to HIPAA confidentiality rules and regulations.

1. Demonstrates critical thinking skills in identifying any significant changes in the patients situation.

1. Identifies and works to close gaps in the continuum of care that could impact health status.

1. Performs special projects and other duties as assigned.

Qualifications :

Education & Training: High school diploma or equivalent is required. Associates degree preferred.

Work Orientation & Experience: One (1) year of experience in a medical office setting or healthcare environment required.  Previous electronic medical record experience preferred. Knowledge of medical and insurance terminology and navigating the healthcare system required.

Skills & Abilities:  Demonstrate skill in a) customer service; b) oral and written communication to address inter- and intradepartmental concerns solve problems and address conflict; c) working knowledge of sanitation personal hygiene and basic health and safety precautions applicable for work in a clinical setting; d) effective use of EMR e-mail the internet word processing spreadsheets presentation and database packages etc. e) navigating the health care system and providing resources to patients.  Demonstrate ability to a) problem solve and use available resources in innovative ways; b) understand and follow oral and written instructions generally acquired through a high school education and medical assistant programming; c) document and communicate pertinent information; d) establish and maintain effective working relationships with patients and the care team; e) demonstrate an understanding and sensitivity to serving culturally diverse population while respecting patient confidentiality; and f) must have reliable transportation.

Additional Information :

All your information will be kept confidential according to EEO guidelines.

 Compensation:

• Full-Time; Days M-F (8am-4:30pm)
• Pay Range: $17.89 - $23.59
• Review the 2025-2026 UMMS Benefits Guide

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Remote Work :

No

Employment Type :

Full-time