Patient Care Coordinator
Job Summary
The Patient Care Coordinator supports the organization’s population health and value-based care initiatives by proactively identifying and closing gaps in patient care. This position is responsible for coordinating patient outreach, scheduling Medicare Annual Wellness Visits and other preventive services, supporting chronic care management initiatives, and coordinating wellness and population health projects.
The Patient Care Coordinator works closely with patients, providers, clinical staff, and administrative teams to improve patient access, preventive care, quality outcomes, and overall patient engagement. The position requires excellent communication, organization, attention to detail, follow-through, and the ability to work independently while maintaining strong collaborative relationships across the organization.
Duties and Responsibilities
Patient Outreach & Gap Closure
Identify patients with open preventive, chronic care, and quality-of-care gaps through designated reports, registries, and electronic health record systems.
Conduct proactive patient outreach by telephone and other approved communication methods to address identified care gaps.
Educate patients regarding recommended preventive services, screenings, immunizations, and routine healthcare needs.
Schedule patients for appropriate services and follow up as needed to ensure completion.
Document all patient outreach, scheduling, and care-gap activities accurately and timely in the appropriate systems.
Collaborate with providers, nurses, medical assistants, and other staff to resolve barriers to care.
Monitor assigned patient populations and follow up on outstanding gaps to support organizational quality goals and value-based care initiatives.
Assist with tracking and reporting care-gap closure progress.
Wellness Visit Coordination
Coordinate and schedule Medicare Annual Wellness Visits and other preventive wellness appointments.
Conduct patient outreach to educate eligible patients about the importance and benefits of wellness visits.
Maintain and utilize scheduling lists, reports, and tracking tools to identify patients due or overdue for wellness services.
Coordinate with clinic staff and providers to ensure appropriate scheduling and preparation for wellness visits.
Follow up with patients who are unable to schedule or complete their wellness visit.
Assist in developing and maintaining processes designed to improve wellness visit completion rates.
Wellness & Population Health Projects
Coordinate assigned wellness and population health projects from planning through completion.
Assist with developing patient outreach lists, tracking spreadsheets, reports, educational materials, and other project resources.
Coordinate communication between departments and team members involved in wellness initiatives.
Monitor project progress and communicate barriers, needs, and outcomes to leadership.
Participate in quality improvement initiatives designed to improve patient outcomes and organizational performance.
Assist with special projects related to preventive care, quality measures, patient engagement, and value-based care.
Chronic Care Management Support
Coordinate assigned chronic care management projects and patient outreach initiatives.
Assist in identifying eligible patients and supporting enrollment or engagement activities as directed.
Conduct outreach to patients regarding chronic disease management needs, follow-up appointments, preventive services, and recommended care.
Coordinate with clinical staff to ensure identified patient needs are communicated appropriately.
Track assigned chronic care management activities and maintain accurate documentation.
Assist with identifying opportunities to improve patient engagement, continuity of care, and chronic disease outcomes.
Professional Requirements & Expectations
The Patient Care Coordinator is expected to consistently demonstrate professionalism, reliability, accountability, and a commitment to patient-centered care.
Ensures that appearance and personal conduct are professional at all times.
Maintains an excellent attendance record and demonstrates reliability and punctuality.
Wears appropriate clothing for assigned job functions and wears the required organization ID badge.
Works to maintain a positive rapport and cooperative working relationship with physicians, administration, clinical staff, and coworkers.
Demonstrates respect, courtesy, and professionalism in all interactions.
Represents the organization positively and professionally in the community.
Maintains patient confidentiality at all times and protects patient information in accordance with HIPAA and organizational policies.
Complies with all organizational policies regarding ethical business practices.
Maintains HIPAA compliance in all patient interactions, documentation, communication, and use of electronic systems.
Preferred Qualifications
Previous experience in a healthcare, medical office, care coordination, population health, or patient outreach setting.
Experience with electronic health records and healthcare scheduling systems.
Experience with patient outreach, quality measures, care-gap closure, wellness visits, or chronic care management preferred.
Knowledge of Medicare preventive services and value-based care concepts preferred.
Strong computer, organizational, communication, and customer service skills.
Ability to manage multiple projects and priorities while meeting established deadlines.
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