Integrated Care Coordinator

Nuvance Health Med Practice PC•Sharon, CT

106d•$41 - $76

About The Position

The Integrated Care Coordinator plays a vital role within the Nuvance Health Primary Care team, acting as a bridge between clinical services and community-based wellness resources for older adults. This position is embedded in Primary Care offices, where the Coordinator collaborates closely with clinicians, nurses, and care teams to transform wellness goals into practical, accessible services. By addressing social determinants of health (SDOH) through integrated care coordination, the role promotes aging in place, reduces health disparities, and strengthens person-centered care.

Requirements

Bachelor’s degree in Social Work, Public Health, Nursing, Human Services, Gerontology, or related field.
Minimum of three (3) years of experience in case management, care coordination, or community health.
Familiarity with aging services, health disparities, and integrated care models.
Strong interpersonal and communication skills, with the ability to work in a fast-paced clinical setting.
Proficiency with EHR systems and electronic documentation.
Valid driver’s license and reliable transportation for occasional field visits.

Responsibilities

Collaborates with primary care clinicians to identify NY-based patients who would benefit from wellness and social support services.
Conducts in-office or telehealth wellness assessments aligned with clinical recommendations.
In coordination with the care team, create and implement personalized individual and family care plans, which are dynamic, ongoing, and based on the patientï¿½s needs and goals.
Connects patients to community-based programs (e.g., transportation, nutrition, exercise, CDSME workshops, home support).
Addresses barriers to participation such as access, financial constraints, or eligibility.
Monitors patient engagement and outcomes through follow-up visits and documentation.
Participates in daily huddles, case conferences, and care planning meetings with primary care staff.
Serves as a liaison between Nuvance Health and external partners in the community.
Supports provider education on referral pathways and community programs.
Assists with outreach efforts to increase awareness of integrated wellness services.
Documents all patient interactions in the electronic health record (EHR) and case management system.
Tracks referral activity, review utilization patterns, service engagement, and patient outcomes.
Provides regular feedback to the care team and contribute to program evaluation efforts.
Fulfills all compliance responsibilities related to the position.
Maintains and models Nuvance Health foundational values.
Demonstrates regular, reliable and predictable attendance.
Performs other duties as required.