Job Description: Summary
The Care Coordinator works under the direction of the RN Care Manager and partners with primary care providers, patients, caregivers, and interdisciplinary healthcare teams to support care management activities in the outpatient setting.
This role is responsible for assisting with care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, and clinical documentation to improve patient outcomes, reduce avoidable hospital utilization, and enhance the overall patient experience.
This position is ideal for a Certified Medical Assistant (MA) with strong clinical knowledge, excellent communication skills, and a passion for patient-centered care.
How will you make an impact & Requirements
Care Coordination
Support the RN Care Manager in implementing and monitoring individualized care plans.
Conduct routine chart reviews to identify care gaps, preventive care opportunities, and patient needs.
Track referrals, follow-up appointments, diagnostic testing, and care plan objectives.
Coordinate care across primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community organizations.
Collaborate with interdisciplinary team members to ensure continuity of care.
Patient Outreach & Engagement
Conduct telephonic outreach to patients and caregivers.
Identify barriers to care including transportation, medication access, financial concerns, health literacy, and social determinants of health.
Encourage participation in preventive care and chronic disease management programs.
Build strong, trusting relationships with patients and caregivers.
Transitions of Care
Support patients following hospitalizations, emergency department visits, or skilled nursing facility stays.
Assist with post-discharge follow-up, appointment scheduling, medication reconciliation support, and care coordination activities.
Coordinate community resources, services, and equipment needed to support successful recovery and ongoing care.
Communicate critical patient information to providers and care team members to facilitate timely interventions.
Patient Education • Reinforce provider-directed education related to
- Chronic disease management
- Medication adherence
- Preventive health measures
- Self-management strategies
- Community resources and support programs
- Connect patients with prescription assistance programs, transportation resources, support services, and community-based organizations.
Documentation & Record Management
Maintain accurate and timely documentation within the electronic health record (EHR).
Obtain and manage external medical records, discharge summaries, consult notes, and test results.
Track patient outreach efforts, care management activities, quality metrics, and outcomes.
Resource Coordination & Advocacy
Assist patients in accessing clinical, behavioral health, social, and community resources.
Serve as a patient advocate while promoting patient-centered care.
Escalate clinical concerns to the RN Care Manager and providers as appropriate.
Maintain current knowledge of local, state, and federal community resources.
Qualifications
- Current Medical Assistant certification.
- BLS certification preferred.
- Experience
- Minimum of three (3) years of healthcare experience in a physician practice, outpatient clinic, care management, population health, case management, transitional care, home health, or a related healthcare setting preferred.
- Experience supporting chronic disease management and high-risk patient populations preferred.
- Proficiency with electronic health record (EHR) systems required.
- Knowledge, Skills & Abilities
- Strong organizational and time-management skills.
- Excellent verbal and written communication abilities.
- Ability to effectively engage patients and caregivers.
- Knowledge of care coordination, transitions of care, and population health principles.
- Understanding of chronic disease management and preventive care strategies.
- Strong documentation and computer skills.
- Ability to work independently while collaborating effectively with interdisciplinary teams.
- Bilingual skills are a plus.
About Millennium Physician Group
Formed in 2008 and headquartered in Fort Myers, Florida, with offices in Florida, North Carolina, Georgia, and Texas, Millennium Healthcare is the largest independent physician group in the state of Florida and one of the largest in the United States. At Millennium Physician Group, our employees are the foundation of our success. Our promise is to provide you with the tools to do your job successfully, as well as providing a team atmosphere that empowers you to seek better ways to deliver care to our patients and their families. We also promise to care for you as an individual and help you grow in your role.
What We Offer
- Health, Dental, and Vision Insurance
- 401(K) Retirement Plan with Matching
- Short & Long-Term Disability
- Employer-Paid Life Insurance
- Paid Time Off, Floating Holidays, and Paid Major Holidays
- Employee Assistance Program (EAP)
- and much more!
How to Apply
ARE YOU READY TO JOIN OUR TEAM? We understand your time is valuable, and that is why we have a very quick and easy application process. If you feel that you are right for this position, please fill out our initial 3-minute, mobile-friendly application so that we can review your information. We look forward to meeting you!
Compensation Range
$19.00
to
$28.50
The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.
