Care Coordinator - Marietta

Fortis Care•Marietta, GA

6d•Hybrid

About The Position

The Care Coordinator plays a key role in supporting patients with complex medical needs. Working under the supervision of the Manager, Chronic Care Management, you will work directly with patients, providers, and care teams to ensure coordinated, patient-centered care. This role emphasizes patient engagement, care planning, and ongoing follow-up to prevent unnecessary hospitalizations and promote better health outcomes.

Requirements

Must be a Licensed Practical Nurse (LPN) or Certified Medical Assistant (MA).
Minimum 1–2 years of experience in chronic care management, primary care, ambulatory care, skilled nursing, or hospital settings.
Experience with care management documentation and EHR systems preferred.
Associate’s degree or higher in a clinical or health-related field preferred.
Preference given to those with experience in a skilled nursing setting.
Ability to spend 5 days per week on site with some flexibility to work remotely in the afternoons.

Nice To Haves

Strong clinical knowledge of chronic disease management.
Excellent communication skills (verbal, written, and listening).
Ability to engage with patients and families in a supportive, empathetic, and culturally competent manner.
Strong organizational skills and attention to detail.
Ability to work independently while collaborating with providers and team members.
Problem-solving skills with a focus on patient-centered outcomes.

Responsibilities

Deliver chronic care management services to patients with complex or high-risk conditions.
Conduct assessments of medical, educational, and psychosocial needs using standardized tools (e.g., depression, functional, and risk assessments).
Collaborate with providers, specialists, and families to support development and updates of individualized care plans.
Help identify and prioritize patients for medical services each day, including prepping any charts to enable efficient and effective provider visits.
Provide patient and family education, focusing on self-management and capacity for self-care.
Coordinate care transitions, including timely post-hospital follow-up, medication reconciliation, and education on discharge instructions.
Document all care management activities accurately and in a timely manner.
Participate in process improvement activities and quality initiatives.