Codman Square Health Center Inc
Care Management Coordinator
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Description
Position Summary:
Reporting to the Nurse Supervisor of Care Management, the Care Management Coordinator is responsible for supporting the coordination and delivery of care management services for high-risk and complex patients. This role serves as an operational and clinical support resource to ensure effective care coordination, patient engagement, and timely follow-up across the continuum of care.
The Care Management Coordinator works closely with nurses, providers, and interdisciplinary teams to support population health initiatives, reduce care gaps, improve patient outcomes, and enhance access to services through proactive outreach and coordination.
Primary Responsibilities:
Care Coordination & Patient Outreach
General:
- Support coordination of care management services for high-risk, high-utilizing, and complex patients
- Conduct patient outreach via phone calls, MyChart messages, and other communication methods for follow-up, care coordination, and appointment scheduling
- Assist with post-visit and post-discharge follow-up to ensure continuity of care
- Support scheduling and coordination of specialty care, referrals, and internal services
- Facilitate communication between patients, providers, and care teams
Population Health & Panel Management
- Support identification and outreach to patients with care gaps (e.g., missed visits, preventive screenings, chronic disease management needs)
- Assist in managing patient panels and tracking outreach efforts and outcomes
- Work with care management nurses to prioritize outreach based on risk stratification
- Support initiatives aimed at improving key population health metrics (e.g., follow-up rates, reduced no-shows, chronic disease outcomes)
Care Management Workflow Support
- Assist care management nurses with coordination of care plans and follow-up activities
- Support documentation of outreach, coordination activities, and patient interactions in the EHR
- Track referrals, authorizations, and follow-up tasks to ensure timely completion
- Help maintain organized workflows and tracking systems for care management activities
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Administrative & Operational Support
- Coordinate scheduling for care management visits and follow-up appointments
- Assist patients with navigation of services, including insurance, transportation, and community resources
- Support completion of required documentation and reporting for care management programs
- Maintain logs, tracking tools, and reports related to care management activities
- Assist with inventory or resource coordination as needed for patient support services
Quality & Performance Support
- Support tracking and reporting of care management metrics and outcomes
- Assist in identifying workflow gaps and opportunities for improvement
- Participate in quality improvement initiatives related to care coordination and population health
- Ensure adherence to organizational workflows, policies, and documentation standards
Collaboration & Communication
- Collaborate with interdisciplinary teams including nursing, providers, behavioral health, and community partners
- Serve as a point of contact for patients navigating care management services
- Communicate effectively with team members regarding patient needs, follow-up requirements, and care coordination updates
- Participate in team meetings and huddles as appropriate
Other Duties and Responsibilities
- Perform additional duties as assigned to support organizational priorities, patient care coordination, and population health initiatives
Requirements
Qualifications & Skills:
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- High school diploma or equivalent required; completion of an accredited Medical Assistant program or related healthcare training strongly preferred
- Medical Assistant certification (CMA, RMA, or equivalent) preferred
- Minimum of two (2) years of experience in an ambulatory care, community health, or care coordination setting required
- Experience with patient outreach, scheduling, and care coordination strongly preferred
- Familiarity with population health concepts and care management workflows preferred
- Experience with EHR systems (Epic preferred)
- Strong organizational and time management skills with ability to manage multiple tasks
- Strong communication and interpersonal skills with ability to engage diverse patient populations
- Ability to work collaboratively within interdisciplinary teams
- Basic understanding of healthcare systems, insurance, and community resources preferred
- Commitment to patient-centered care and improving health outcomes
Physical Requirements:
- Must be able to stand or sit for prolonged periods (at least 50% of the time)
- Ability to lift up to 25 pounds and load onto shelves
- Visual acuity sufficient for frequent reading and computer use
Benefits:
CSHC offers a generous benefits package including:
- Competitive Medical and Dental Insurance
- Employer-paid Life, Accidental Death & Dismemberment, and Long-Term Disability Insurance
- Retirement-403(b) plan
- Vacation, Holiday, Personal and Sick Time Accruals
- Flexible Spending Reimbursement Accounts (Health and Dependent Care)
- Educational Assistance and Tuition Reimbursement Programs
- Commuter Benefits
- Opportunities for academic appointment at Boston University / Boston Medical Center
Pay Range:
$26.00 to $40.51 Hourly. Compensation is commensurate with years of experience.
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