Care Coordinator

Millennium Physician Group•Port Charlotte, FL

28d•$20 - $31•Remote

About The Position

Millennium Physician Group is seeking a friendly, compassionate Care Coordinator to join its Care Management team. Working under the direction of the RN Care Manager, the Care Coordinator collaborates with primary care providers, patients, caregivers, and interdisciplinary team members to support outpatient care management. The role supports care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, and documentation to improve patient outcomes, reduce avoidable utilization, and enhance the patient experience. The position may be filled by a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience. The Care Coordinator assists with individualized patient care plans, patient engagement and education, follow-up after emergency department visits and hospitalizations, medical record management, and access to clinical, social, behavioral health, and community services. The position reports directly to the RN Care Manager and works collaboratively with physicians, advanced practice providers, care managers, case managers, social workers, and other healthcare team members. The role is primarily remote, with possible work at an MPG main office and/or outpatient clinic. It involves telephonic patient outreach, care coordination activities, and occasional interaction with community agencies and healthcare facilities. Compensation is listed as $19.80 to $31.35; the posting does not specify the pay period.

Requirements

One of the following: a current Florida Licensed Practical Nurse (LPN) license, or Certified Medical Assistant (CMA/RMA) or equivalent Medical Assistant certification from an accredited program (the MA certification is listed as preferred).
LPN applicants must have an active, unrestricted Florida LPN license.
Medical Assistant applicants must maintain current certification, if applicable.
Electronic health record (EHR) experience is required.
Strong organizational and time-management skills.
Excellent verbal and written communication skills.
Ability to build rapport and effectively engage patients and caregivers.
Knowledge of care coordination principles, transitions of care, and population health management.
Understanding of chronic disease management and preventive care strategies.
Ability to identify barriers to care and coordinate appropriate interventions.
Strong documentation and computer skills.
Ability to work independently while collaborating closely with the RN Care Manager and interdisciplinary care team.

Nice To Haves

Current BLS certification is preferred.
A minimum of three years of clinical healthcare experience in a physician practice, outpatient clinic, population health, care management, case management, transitional care, home health, or related setting is preferred.
Experience with chronic disease management and high-risk patient populations is preferred.
Bilingual skills are a plus.

Responsibilities

Assist the RN Care Manager in implementing and monitoring individualized patient care plans.
Perform monthly patient chart reviews to identify care gaps, preventive care needs, and opportunities for intervention.
Monitor and track follow-up appointments, referrals, diagnostic testing, and care plan goals.
Coordinate services among primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community organizations.
Collaborate with the healthcare team to support continuity of care across settings.
Conduct telephonic outreach to patients and caregivers as directed by the RN Care Manager.
Assess barriers to care, including transportation, medication access, financial concerns, health literacy, and social determinants of health.
Encourage patient participation in care plans, preventive services, and chronic disease management programs, and build trusting relationships with patients and caregivers.
Support transitions of care following emergency department visits, hospitalizations, and skilled nursing facility stays.
Assist with post-discharge follow-up, appointment scheduling, medication reconciliation support, and identification of ongoing care needs.
Coordinate necessary services, equipment, and community resources before or after discharge.
Communicate pertinent information to providers and care team members to facilitate timely interventions.
Reinforce education from the RN Care Manager and providers about chronic disease management, medication adherence, preventive health, self-management, and community resources.
Provide information about prescription assistance programs, transportation services, community resources, and support groups as appropriate; refer to ACO pharm to assist with PAP.
Maintain accurate, timely, and complete documentation in the electronic health record.
Obtain and upload medical records, discharge summaries, consult notes, and test results from hospitals, specialists, skilled nursing facilities, and other providers.
Track care management activities, outreach attempts, patient outcomes, and quality metrics.
Assist patients in accessing appropriate clinical, social, behavioral health, and community-based services.
Maintain knowledge of local, state, and federal community resources; advocate for patient needs and promote patient-centered care.
Escalate clinical concerns to the RN Care Manager or provider as appropriate.