Geriatric Care Coordinator

Millennium Physician Group•Fort Myers, FL

About The Position

The Geriatric Care Coordinator serves as a vital link between our elderly patients, their families, and the multidisciplinary care team. This role is crucial for ensuring seamless patient navigation, comprehensive administrative support, and coordination of care services, ultimately contributing to the highest quality of patient outcomes. The Geriatric Care Coordinator guides patients through basic access-to-care steps by confirming needs, documenting requests, sharing standard information, and routing questions to the appropriate care team or service area. Coordinates routine appointment, referral, transportation, community resource, and follow-up support using established workflows and approved patient communication practices. Performs routine clinical support tasks under close supervision, following established checklists and protocols to ensure accurate execution. Decisions reference clearly defined procedures and have limited impact beyond own work. This job applies basic clinical support skills to well-defined tasks, with work reviewed routinely by licensed clinical staff.

Requirements

Previous experience in a healthcare administrative or patient care coordination role is preferred, especially in a geriatric or primary care setting.
Proficiency with Electronic Health Record (EHR) systems (e.g., Athena) and scheduling platforms (e.g., Carelink).
Strong understanding of medical terminology, insurance verification, authorization processes, and common clinical workflows (e.g., lab orders, referrals, prescription refills).
Exceptional organizational skills, attention to detail, strong verbal and written communication, and a compassionate, patient-centered approach.

Responsibilities

Coordinate, schedule, and confirm new and existing patient appointments using systems like Athena and Carelink; place reminder calls to patients.
Act as the primary liaison, communicating regularly with patients, family members, and various providers and care teams (including specialists, PCPs, home health, and hospice agencies).
Coordinate and schedule post-discharge visits for patients returning home from the hospital or skilled nursing facilities (SNF).
Monitor and manage the coordination of new patient referrals, specifically for house calls.
Process and track specialized referrals (e.g., specialists, home health, hospice, psychiatry), including faxing orders/referral packets and progress notes, and following up to confirm acceptance and scheduling.
Enroll eligible patients in Advanced Primary Care Management (APCM), creating the necessary profiles and uploading consent forms; accurately document time spent on APCM tasks (e.g., home health orders, prescription management, phone calls).
Track referrals, discuss program details with patients, and set up in-person or telehealth visits, including confirming insurance and location details.
Screen and return phone calls to family members on behalf of the Nurse Practitioner (NP).
Perform patient registration, creating profiles in Athena, and accurately adding/verifying patient demographics, new patient insurance, and billing information.
Upload admission packets as needed.
Maintain and track provider census data, monitoring patient appointment cadence, referral status, and ensuring accurate provider and regional assignments in Athena and other tracking systems.
Verify patient insurance benefits.
Obtain necessary insurance authorizations for specialist referrals, APCM, Transitional Care Management (TCM) services, and medications.
Document after-hours call notes in the patient chart.
Assist with tasks related to practice capacity, general letters, and processing provider requests/orders.
Process lab and radiology orders, including faxing orders and demographics for mobile imaging.
Manage the Lab bucket by labeling/assigning reports and contacting patients to deliver lab results on behalf of the NP.
Complete and process Durable Medical Equipment (DME) orders, add addenda to progress notes, fax the order and face sheet to the vendor, and call to confirm receipt.
Verify medication dosage and frequency in the EHR and submit prescription refills on behalf of the NP.
Send orders for acute issues to Assisted/Independent Living facilities (AL/IL) on behalf of the NP.
Send medical records requests on behalf of the NP; fax progress notes and records to specialists, PCPs, home health, and hospice agencies for care coordination.
Track and manage death certificate requests.
Send home health certifications to the Central Business Office (CBO).
Serve as a liaison for unprocessed medical records requests between HealthMark and the patient/requestors.