Job Description

Job Title:                       Care Coordinator

Reports To:                   Care Coordination Supervisor

Job Summary:                     Collaborates with clinical team members, patients, and families to facilitate unmet health care needs within the context of the Patient Centered Medical Home (PCMH) model.


Essential Job Duties and Responsibilities:

The job duties and responsibilities listed below are representative of the knowledge, skill, and/or ability required.  Other duties that fall within the broad scope of this classification may be assigned.

  • Promotes the PCMH Model
    • Assists in promoting and implementing PCMH initiatives.
    • Regularly participates in leadership, staff, and other quality improvement meetings to educate staff and facilitate participation in PCMH initiatives.
    • Represents CCHCI’s implementation of PCMH within the context of institutional and community forums.
    • Performs duties related to Quality Department projects as assigned.


  • Promotes and Provides Care Coordination
  • Coordinates preventative health care measures and health care maintenance for defined patient populations.
  • Manages insurance company correspondence regarding patient care.
  • Identifies and tracks patients in need of follow up and other testing for chronic disease management in collaboration with provider.
  • Follows up on missed appointments for defined patient populations.
  • If within scope, provides patient education for disease management and assists providers with lab and diagnostic study follow up.
  • Organizes and facilitates care planning for defined patients.
    • Arranges in-home medical care such as home health, hospice, and in-home durable medical equipment and oxygen needs.
  • Facilitates hospital admissions.
    • Tracks and coordinates follow up of hospitalized patients upon discharge and obtains in-patient medical records.


  • Coordinates Specialty Care
  • Builds and maintains relationships with specialists and other medical services.
    • Negotiates rates for underinsured and uninsured populations.
  • Follows up on outstanding referrals.
    • Assists patient with potential barriers to specialty care.
  • Coordinate in-house clinics for visiting specialists in collaboration with leadership team.
    • Manages and submits necessary documentation to insurance for coverage of transportation.
    • Negotiates rates with local transportation companies for uninsured populations.


Minimum Qualifications - Experience, Certificates & Licenses:

  • High School Diploma or GED
  • At least two years of experience in case management, nursing, or other related health care field.
  • Any combination of education and/or experience that provides the necessary skills required may be considered.
  • CPR certification may be required for licensed staff.
  • Valid Fingerprint Clearance Card may be required.

Preferred Qualifications - Experience, Certificates & Licenses:

  • Associate degree in a field of case management, social work, or related field preferred.


Required Language Skills:

  • Ability to comprehend and compose instructions, correspondence and communications in English and Spanish in both oral and written format.
  • Bilingual in English and Spanish with knowledge of medical terminology is required.


Physical Requirements:

  • Ability to frequently exert enough force to move objects weighing up to 25 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to frequently move about inside the workplace to assist patients, operate office or medical equipment, etc.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, and other office machinery.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.

Other Required Knowledge, Skills, and Abilities:

  • Ability to add, subtract, multiply and divide in all measure, using whole numbers, common fractions, and decimals.
  • Ability to gather data in an organized fashion from varied sources.
  • Ability to perform a variety of assignments with little or no direct supervision.
  • Ability to identify and resolve problems in a timely manner.
  • Knowledge of health plans and community health centers preferred.
  • Knowledge of HIPAA rules and regulations.
  • Computer literacy required with proficiency in use of all Microsoft Office programs.
  • Ability to provide excellent customer service by mail, telephone, and in-person.


Work Environment & Conditions:

  • Work environment is typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids, and hazardous chemicals.
  • Occasionally, work requires extended hours to include early mornings, evenings, and weekends.