Care Coordinator II

Summary

Millennium Physician Group is seeking a Care Coordinator II to support outpatient care management. The role assists the RN Care Manager with care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, patient education, and clinical documentation to improve outcomes and patient experience.

Responsibilities

• 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
• 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
• 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 identification of ongoing care needs
• Ensure necessary services, equipment, and community resources are coordinated prior to or following discharge
• Communicate pertinent information to providers and care team members to facilitate timely interventions
• Reinforce education provided by the RN Care Manager and providers regarding:
• Chronic disease management
• Medication adherence
• Preventive health measures
• Self-management strategies
• Community resources and support programs
• Provide information on prescription assistance programs, transportation services, community resources, and support groups as appropriate. Refer to ACO pharm to assist with PAP
• Maintain accurate, timely, and complete documentation within the electronic health record (EHR)
• Obtain and upload medical records, discharge summaries, consult notes, and test results from hospitals, specialists, skilled nursing facilities, and other providers
• Track care management activities, outreach attempts, patient outcomes, and quality metrics
• Assist patients in accessing appropriate clinical, social, behavioral health, and community-based services
• Maintain knowledge of local, state, and federal community resources
• Advocate for patient needs and promote patient-centered care
• Escalate clinical concerns to the RN Care Manager or provider as appropriate

Skills

• Candidates must be located in the Sarasota, Bradenton, Englewood, Venice, Port Charlotte, Punta Gorda Area
• The Care Coordinator may be a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience
• Current Florida Licensed Practical Nurse (LPN) license; or
• LPN applicants must possess an active, unrestricted Florida LPN license
• Medical Assistant applicants must maintain current certification, if applicable
• Experience with electronic health records (EHR) required
• Strong organizational and time-management skills
• Excellent verbal and written communication skills
• Ability to build rapport and effectively engage patients and caregivers
• Knowledge of care coordination principles, transitions of care, and population health management
• Understanding of chronic disease management and preventive care strategies
• Ability to identify barriers to care and coordinate appropriate interventions
• Strong documentation and computer skills
• Ability to work independently while maintaining close collaboration with the RN Care Manager and interdisciplinary care team
• Certified Medical Assistant (CMA/RMA) or equivalent Medical Assistant certification from an accredited program (Preferred)
• Current BLS certification preferred
• Minimum of three (3) years of clinical healthcare experience in a physician practice, outpatient clinic, population health, care management, case management, transitional care, home health, or related setting preferred
• Experience working with chronic disease management and high-risk patient populations preferred
• Bilingual skills are a plus

Qualifications

Must Haves

• Candidates must be located in the Sarasota, Bradenton, Englewood, Venice, Port Charlotte, Punta Gorda Area
• The Care Coordinator may be a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience
• Current Florida Licensed Practical Nurse (LPN) license; or
• LPN applicants must possess an active, unrestricted Florida LPN license
• Medical Assistant applicants must maintain current certification, if applicable
• Experience with electronic health records (EHR) required
• Strong organizational and time-management skills
• Excellent verbal and written communication skills
• Ability to build rapport and effectively engage patients and caregivers
• Knowledge of care coordination principles, transitions of care, and population health management
• Understanding of chronic disease management and preventive care strategies
• Ability to identify barriers to care and coordinate appropriate interventions
• Strong documentation and computer skills
• Ability to work independently while maintaining close collaboration with the RN Care Manager and interdisciplinary care team

Nice to Haves

• Certified Medical Assistant (CMA/RMA) or equivalent Medical Assistant certification from an accredited program (Preferred)
• Current BLS certification preferred
• Minimum of three (3) years of clinical healthcare experience in a physician practice, outpatient clinic, population health, care management, case management, transitional care, home health, or related setting preferred
• Experience working with chronic disease management and high-risk patient populations preferred
• Bilingual skills are a plus

Benefits

• Primarily based remotely
• May be in an MPG main office and/or an outpatient clinic