High Risk Care Coordinator
About The Position
The High Risk Care Coordinator provides psychosocial support, care coordination, and serious illness guidance for high risk and medically complex patients in a value based primary care setting. This role focuses on patients with advanced chronic conditions, functional decline, frequent utilization, or complex social needs. The coordinator collaborates with physicians, nurse case managers, and interdisciplinary teams to address barriers to care, support care transitions, facilitate advance care planning, and coordinate services across the continuum of care. The role integrates social work principles, care coordination, and end of life support to improve quality of life and reduce avoidable utilization The High Risk Care Coordinator supports population health outcomes by: Reducing avoidable emergency visits and hospitalizations Improving transitions of care and post discharge follow up Increasing advance care planning and goals of care documentation Facilitating appropriate use of palliative care and hospice services Addressing social determinants of health impacting outcomes Supporting patient engagement and care plan adherence
Requirements
- MSW preferred (completed or in progress), or MPH or bachelor’s degree in healthcare administration, Social Work, Public Health, or related field.
- Experience in hospice, palliative care, care coordination, or healthcare operations preferred.
- Experience working in interdisciplinary teams.
- Familiarity with EHR documentation and healthcare compliance
- Skilled in use of computer/EMR systems.
- Knowledge of Word processing software, spreadsheet software, Internet, and database software.
- Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 20 lbs. without assistance.
- Close vision and ability to adjust focus.
- Must be able to work efficiently under pressure.
Nice To Haves
- End of Life Doula Certification is preferred.
- Training in palliative care, hospice care, or serious illness communication preferred
Responsibilities
- Conduct psychosocial and supportive care assessments for high risk patients
- Provide emotional support, counseling, and guidance for patients and families
- Identify and address social determinants impacting care and outcomes
- Collaborate with physicians and care teams to develop and support individualized care plans
- Coordinate referrals to community resources, behavioral health, home health, palliative care, and hospice
- Support care transitions including hospital discharge and post acute follow up
- Participate in interdisciplinary care management meetings
- Facilitate advance care planning and goals of care discussions
- Educate patients and families on palliative care and hospice services
- Provide supportive presence and guidance aligned with end of life care principles
- Document assessments, interventions, and coordination activities in the electronic health record
- Ensure compliance with HIPAA and organizational policies
- Support quality and population health initiatives
- Maintain knowledge of community resources and supportive services
- Participate in ongoing professional development
- Support organizational goals related to value based care and patient outcomes
- Perform other duties as assigned
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
