Care Coordinator I (ICP)

HonorHealth•Mountain View, AZ

20d•Onsite

About The Position

The Care Coordinator I collaborates with primary physicians and other healthcare team members to develop patient-centered goals and actions that reflect the patient’s and family’s care needs and resources. The coordinator advocates for patients throughout the continuum of care and serves as a resource to physicians, patients, and families to facilitate communication. This role provides coaching and care coordination to assigned patients during transitions among ambulatory care, hospital, home, and skilled nursing settings, with an emphasis on health, wellness, and care coordination. The coordinator coaches patients and caregivers in self-management and recovery, coordinates follow-up and post-discharge care, and works with clinical practitioners and internal and external healthcare partners. The role includes outbound calls, home visits, appointment scheduling, accurate encounter documentation, medication reconciliation support, and connection to community resources. The coordinator manages a high-volume caseload independently, adapts to changing priorities, and collaborates with HonorHealth staff and community organizations to meet patient needs.

Requirements

High school diploma or GED.
At least 1 year of experience in outpatient, ambulatory care, specialty care, or community healthcare.
Basic Life Support (BLS) certification and CPR card.
Current State of Arizona Fingerprint Clearance Card within 8 weeks of hire for employees who conduct home visits.

Nice To Haves

Associate degree in business, health administration, or a related field.
At least 2 years of experience in an outpatient clinical setting working with primary care providers.
Home care experience.
Preference given to honorably discharged veterans.
EMT-Basic license, MA, EMT, Paramedic BLS, or equivalent military experience.

Responsibilities

Collaborate with physicians and healthcare team members to develop realistic, patient-centered goals and actions.
Advocate for patients throughout the care continuum and facilitate communication among physicians, patients, and families.
Coach patients and caregivers on critical issues and self-management tasks using active listening, Behavioral Motivational Interviewing, guided goal setting, and home visits.
Document every patient encounter accurately and completely.
Coordinate with clinical practitioners to review patient progress and ability to manage health issues.
Educate and empower patients and caregivers to support health management and help prevent avoidable use of additional resources or hospital admissions.
Conduct outbound calls and home visits and schedule appointments as necessary.
Assist with medication reconciliation, post-discharge home care coordination, self-management support, follow-up and supportive care, advanced care planning, community resources, and long-term planning.
Report patient compliance or non-compliance with medical care instructions to appropriate clinical staff.
Communicate clearly and professionally with clinical teams, patients, and caregivers through email, technology, written, and verbal channels.
Ensure safe handoffs of hospitalized and post-acute care patients from Transitional Care Managers to Care Coordinators.
Coordinate outpatient follow-up appointments and plans of care with primary care providers and specialists.
Coordinate care with internal and external providers and other healthcare team members.
Build and maintain working relationships with patients, caregivers, and healthcare partners.
Manage caseloads independently with minimal direction, organize workflow, handle a high-volume caseload, and adapt to rapidly changing priorities.
Collaborate with HonorHealth staff, social service organizations, and community resources to meet patient needs.
Maintain working knowledge of applicable laws, regulations, and Medicare, Medicaid, SSI, SSDI, and insurance benefits.
Perform other duties as assigned.