Job Title: Care Coordinator

Reports to: Clinical Supervisor, Practice Manager


The Care Coordinator supports the patient-centered medical home (PCMH) by working with patients, families, providers, other providers, and staff to promote timely access to needed care, providing daily continuity of care coordination, and coaching patients, families, and caregivers to understand the patient's care plan and self-care management responsibilities.


• Certified Medical Assistant, LPN or RN licensing with appropriate past experience in healthcare.

• Current, active, and unrestricted registered nursing license or certification in a health or human services discipline that allows the person to conduct independent assessments as permitted within the scope of practice.

• Three to five years’ experience in a primary care practice with duties m leading care coordination, or the equivalent. (See "Relevant Experience.")

Demonstrated skills in leadership, advocacy, communication, education, and counseling.


Ability to apply critical thinking skills and make sound judgments both while performing daily responsibilities and throughout the patient's continuum of care.

Knowledge of the case management process and the patient-centered medical home (PCMH). Knowledge and demonstrated abilities to work in a regulatory climate that includes oversight by federal and state rules, payer contracts, governmental benefits, and community resources.

Effective oral and written communication skills.

Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate accurately and effectively with all levels of staff and management.

Detail-oriented, thorough, and able to handle multiple tasks and projects with varying deadlines and priorities.

Ability to interpret and relay to patients (and their caregivers) the applicable Medicare, Medicaid, or private insurance coverage for ordered services to include information about coverage limits and any costs the patient may incur.

Ability to work successfully in a fast-paced, stressful environment. Ability to work with a registry and an electronic health record.

Empathy, mental alertness, precision, analytical problem-solving abilities, communication skills, focus, and initiative,


Apply the principles of comprehensive, community-based, patient-centered, developmentally appropriate, and culturally and linguistically appropriate care coordination.

Use case management processes to assure quality care is delivered to the Practice's patients, the patients' families, and the patients' caregivers in the most efficient and effective manner across the healthcare continuum.

Engage patients, patients' families, and their caregivers in understanding, setting, and monitoring patient self-management care plans in a manner that is culturally and linguistically appropriate to the patient and caregiver.

Complete health risk assessments as a foundation for developing individualized care plans and outcomes goals for patients and their families.

Document each patient's individualized care plan and care coordination in the Practice's database.

Coordinate the patient's care by facilitating patient, family, or other caregiver access to medical home providers, staff, and resources as needed by the patient.

Conduct and document assessments of patient needs and resources for effective self-care management.

Develop and maintain relationships among patients, patients' families, and the patients' care team that support patients' access to the medical home.

Act as the primary contact point, advocate, and source of information for patients and the community partners who help treat them.

Research, find, and link patients to resources, services, and support mechanisms for their care plans and self-care management needs.

Provide timely communication with patients, make inquiries, execute follow-up actions, and help to integrate information into the care plan.

Assist the care team by helping to measure quality and identify, refine, and implement performance improvements that support the medical home.

Assist the care team in performance evaluation and quality improvement.

Continually monitor the cost effectiveness of services provided through the patient's individualized care plans and recommend any needed changes to those plans based on evidence­ based, clinical guidelines from sources identified by the Practice.

Participate in continuing professional growth through attendance at workshops and professional in-services and through individual research and reading, to include communication skills.

Participate in population management activities as directed by the Practice.

Attend and participate in organized functions of the Practice and perform administrative functions as necessary.

Demonstrate personal responsibility and respect for patients, patients' families, and co­ workers in professional appearance.

Perform duties in a manner that is culturally and, if applicable, linguistically appropriate. Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams with activities to include participating in daily huddles.

Relevant Experience

Certified Medical Assistant, LPN or RN licensing with appropriate past experience in healthcare. Registered Nurse in community health center.

Healthcare experience in an ambulatory setting. Healthcare experience in home care services.

Healthcare experience in social work or in social services. Supporting of patients and families in self-management of their care.

Coordination of community education and support services for patients.

Communication with and provision of feedback to referral sources including physicians, social services, staff, and/or care coordinators.

Provision of education to staff, including individual orientation, in-service programs, and written materials about procedures, protocols, and other processes.

Interface with registries, electronic health record system, and/or databases to document and monitor care.

Kids Health First is an Association of 38 Pediatric Practices located in the Atlanta and surrounding areas. Initial candidate screenings are conducted by our recruiter. All interviews and final decisions are made by the pediatric practices, based on their current individual needs and hiring processes. Salary and benefits are determined by the individual practices.