Care Coordinator

Job Description

Job Description

DISCLAIMER

Job descriptions are not meant to be all-inclusive, and the job itself is subject to change. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Summary

The Care Coordinator serves as the main point of contact for facilities and physicians participating in the High Needs REACH program. This role blends care transition functions with provider consulting responsibilities to ensure patients experience seamless care coordination, facilities achieve measurable performance improvement, and providers are engaged with data-driven insights. The Care Coordinator will work closely with post-acute facilities, physicians, patients, and internal PBACO teams to reduce readmissions, improve quality, and strengthen participant satisfaction.

This position requires strong communication skills, the ability to share and interpret data with stakeholders, and the clinical knowledge to support patients navigating their Medicare benefits. The role requires travel up to two times per month, including overnight stays, to meet with facilities and providers.

Essential Duties and Responsibilities

Care Coordination

• Monitor ADTs (admission, discharge, transfer feeds) to identify outlier information that may impact patient outcomes.
• Alert facilities or participating providers when relevant findings are identified.
• Encourage communication between facilities and participating providers to support collaborative decision-making.
• Promote provider engagement in care planning decisions, including the use of auxiliary services within the residence (e.g., therapy, ancillary support services).

Provider & Facility Engagement

Data & Reporting

Program & Network Support

Key Performance Indicators (KPIs)

Care Coordination & Outcomes

Facility & Provider Engagement

Operational Efficiency & Reporting

Competencies

Qualifications

Physical Demands

Supervisory Responsibilities