State of Franklin Healthcare Associates is a physician-led and team member-owned multi-specialty care group headquartered in Johnson City, Tennessee, serving upper East Tennessee and Southwest Virginia. Its mission is to improve the health and well-being of patients and team members. The Patient Care Coordinator helps patients transition from an inpatient setting back home or to a post-acute setting. The role develops, initiates, and monitors patient self-management plans; uses motivational interviewing to enhance patient outcomes; and coordinates options and services to meet patients’ needs. The coordinator also identifies social determinants of health and connects patients with community resources and social worker support, documents care in the medical record and CareTrac, and assists providers with closing care gaps through patient outreach.
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Job Type
Full-time