Care Coordinator

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The Care Coordinator will provide interdisciplinary care coordination services for the medical clinic. Care Coordination services will include the daily tasks of increasing patients' access to care, advocacy of patient needs, community connection to resources, obtaining medical support needs, assisting with crisis resources, and case management services. Applicants that are empathic, critical thinkers, work well individually and within a care team, are reliable, organized, and proficient with electronic health record systems will align well with this position.

• Serves as the primary point of contact for patients needing assistance navigating healthcare services.
• Coordinates appointments, follow-up visits, referrals, labs, imaging, and specialty care.
• Ensure timely patient outreach for completion of preventive services (annual wellness visits, immunizations, cancer screenings).
• Monitor the electronic medical record (EMR) and other registries to identify patients with care gaps (e.g., diabetes mellitus, hypertension not controlled, overdue colorectal cancer screening).
• Provide outreach to patients who are overdue for care or lost to follow-up.
• Conduct post-discharge calls to support transitions of care after ER visits or hospitalizations.
• Connect patients to community resources, social services, or internal programs (CHWs, physical therapy, dental services, behavioral health).
• Provides trauma informed resource support and assistance to providers for patients in need of emergency shelter due to homelessness and resources for food insecurity.
• Assist with applications or referrals for assistance programs as appropriate.
• Document outreach efforts and patient outcomes in the EHR.
• Participate in quality-improvement initiatives by providing data, insights, and workflow suggestions.
• Track patients for follow-up to meet UDS, HEDIS, or value-based care quality measures.
• Responsible for accurate and timely contributions to all project reporting requirements.
• Attends and participates in other meetings and conferences as appropriate and/or identified by supervisors.
• Identify barriers to patient compliance and assist patients in overcoming such barriers.
• Monitor referrals in EMR for SDOH needs and assist accordingly.
• Propose and follow PDSA's relevant to the above.
• When necessary and appropriate, coordinate care with the family of the patient and clinical staff.

• Provides concentrated effort working with the DM Care Team to include: DM Clinic providers, nursing staff, medical assistants, dieticians, and quality improvement team.
• Serves as first-line point of contact for diabetic patients needing additional support.
• Works with health information technology staff to analyze population‑health reports and identify high‑risk patients for outreach.
• Conducts outreach to patients with a diagnosis of diabetes, uncontrolled A1c levels, overdue labs, or missed appointments.
• Collaborates with medical reception to facilitate timely scheduling of DM Clinic appointments.
• Serves as a source of information for primary care providers and their patients for DM Clinic services.
• Provides patient assistance with connecting to external resources, i.e. endocrinology, podiatry, ophthalmology, nutrition, and behavioral health.
• Tracks and monitors diabetic patients to improve A1c control, blood pressure control, and preventive screenings.
• Supports transitions of care following ED visits or hospitalizations related to diabetes.
• Provide education on blood glucose monitoring, medication adherence, insulin use (if within scope), and lifestyle changes.
• Reviews blood glucose logs with patients and escalates concerns to providers.
• Assist in the coordination of care plans with providers, RNs, dietitians, pharmacists, community health workers, and behavioral health teams.
• Attend team huddles, case conferences, and care‑management meetings.
• Communicate patient progress, barriers, and care‑plan adjustments effectively.
• Teach patients about diabetes pathophysiology, medications,…