Care Coordinator- Plano, TX

Segue Health Management Corp•Plano, TX

About The Position

Segue Health, a faith-based medical practice, is seeking a compassionate Care Coordinator to serve patients in the Plano, Texas area by coordinating post-discharge transitional care management (TCM). The role combines clinical knowledge, organizational ability, and strong communication skills. The position focuses on connecting patients leaving a hospital or other referring facility with follow-up support and in-home visits. Segue Health is a mission-focused organization dedicated to providing Christ-centered care in patients’ homes and communities. Its goal is to support the transition from hospital to home with excellence, empathy, and continuity of care.

Requirements

Experience in the medical field.
Knowledge of Microsoft Excel and the ability to learn EMR/EHR software.
Transportation to and from the local hospital.
A desire to serve others.
Proof of vaccinations or compliance with vaccination requirements per hospital standards.
Strong attention to detail and organizational skills.

Nice To Haves

Experience in social work, nursing, and/or home health.

Responsibilities

Work with referring facilities to generate lists of patients eligible for TCM services.
Visit referrals while they are in the facility to explain the TCM program and identify anticipated needs after discharge.
Log referrals and discharges daily.
Create charts in the EMR and upload face sheets, H&Ps, and discharge summaries.
Call patients within 24 hours after discharge.
Schedule patients, preferably before discharge, for in-home visits.