Job detail

Case Management Coordinator, Care Delivery

University of Maryland Medical System

#HIPAA #Medical Assistant #Population Health #Pharmacy Technician #Patient-Centered Care #SDOH #Community Health Work #Transition Of Care #Heart Failure

Quick overview

The coordinator identifies and enrolls heart failure patients into the Virtual Bridge Clinic to support their transition across care settings. They provide outreach, education, and coordination of medical and social resources to improve patient health outcomes.

Requirements summary

Requires a high school diploma and at least two years of experience in care management, community health, or customer-facing roles. Candidates should possess strong communication skills and the ability to obtain a relevant healthcare certification within one year.

high schoolassociate degreeprofessional certificateCase ManagementHIPAA ComplianceMedical TerminologyPatient EducationCare CoordinationMicrosoft Office SuitePatient OutreachElectronic Medical RecordsInterdisciplinary CollaborationChronic Disease ManagementPatient CoachingSocial Determinants Of Health Screening

Job description

Job Requirements The Case Management Coordinator is responsible for outreaching heart failure patients who are experiencing an acute episode of care, engaging them in the Virtual Bridge Clinic, and supporting their transition across care settings.
This role provides outreach, education, care coordination, and administrative support to ensure patients receive timely follow-up, medication support, and connection to community resources.
Working closely with the RN Care Manager, clinical team, and case management staff, the Case Management Coordinator helps address access to medical and social needs that impact health outcomes.
This position requires strong communication skills, attention to detail, and a commitment to patient-centered care.
Key Responsibilities Patient Identification, Outreach & Enrollment Identify eligible heart failure patients using reports, registries, and clinical data.
Conduct outreach via phone, mail, and in-person encounters to educate patients about the Virtual Bridge Clinic and support enrollment.
Explain the importance of follow-up care, symptom monitoring, and timely access to care.
Transitional Care Support Conduct post-discharge and post-acute Transition of Care (TOC) calls.
Schedule follow-up appointments, labs, and diagnostic tests.
Coordinate referrals to pharmacy, case management, and clinical services.
Support adherence to care plans and reinforce self-management strategies.
Addressing Social Determinants of Health Screen patients using validated tools (e.g., SDOH assessments, PHQ-2/9, high-risk screeners).
Identify barriers such as transportation, food insecurity, housing instability, or medication access.
Provide education on community resources and facilitate referrals to appropriate support services.
Care Team Collaboration Work with the interdisciplinary team to support care coordination activities for heart failure patients.
Communicate patient needs, barriers, and progress to RN Care Managers, pharmacists, and providers.
Assist with screenings, appointment scheduling, and patient education.
Documentation & Administrative Support Document all interactions in the electronic medical record and care management platforms.

Case Management Coordinator, Care Delivery

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Quick overview

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Job description

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