Care Coordinator

General Summary The Care Coordinator demonstrates the CACOST organizational standards of accountability, teamwork, integrity, quality service, and excellence in their everyday duties as a member of the healthcare team. The Care Coordinator performs clinical coordination and patient support activities under the supervision of a licensed healthcare clinician. This role includes pre-visit planning, preventative care support, and patient education in accordance with established Health Center protocols, policies, and procedures.

Primary Responsibilities

• Care Planning Performs comprehensive pre-visit planning utilizing the medical record and applicable external portals to identify gaps in care and appropriate preventative and health maintenance needs and coordinates with the care team and patient as necessary to address identified needs.
• Collaborates with the clinician and the patient to support development of individualized care plans for assigned patients in accordance with clinical guidelines.
• Assesses potential barriers to care, including access, follow‑up needs, or other documented factors that may affect timely healthcare services.
• Care Coordination Coordinates clinical care activities and facilitates communication between patients, clinicians and external healthcare entities to support timely delivery of care across clinical settings.
• Assists in coordinating transitions of care following hospital, external nursing facility, or emergency department discharge.
• Provides support and guidance to staff and patients related to patient care and education, consistent with the health center’s established care coordination model.
• Care Monitoring Utilizes the electronic health record to track laboratory and diagnostic orders and results, transitions of care, and patient follow-up needs.
• Reviews internal and external quality metric data such as UDS measures, HEDIS measures, and payor portals to improve care team quality measures and patient outcomes.
• Patient Care (As Needed) Provided direct patient care on an as-needed basis to support health center operations.
• HIPAA Maintains patient confidentiality in accordance with all applicable federal and state laws and regulations Infection Control Follows established infection control protocols, including proper cleaning and disinfection of clinical areas and equipment, appropriate use of personal protective equipment (PPE), and safe handling and disposal of biohazardous materials and sharps.