Community Care Coordinator - Grace Medical Center
Summary
The Community Care Coordinator works under the oversight of the Community Care Manager or Supervisor, promoting the health and welfare of assigned patients through face‑to‑face and/or phone outreach and e‑mail communications. As a member of the Interdisciplinary Team (IDT), the Coordinator identifies and addresses patients’ individual needs in a timely manner, acts as a patient advocate to address primary physical and social needs, connects patients with community resources, and ensures timely access to necessary services while respecting patients' rights and wishes.
Responsibilities
Contact patients, caregivers, and families to ensure preventive services are received by assigned patients.
Decrease identified care gaps by working with primary care offices to obtain timely appointments, including post‑hospital discharge and annual wellness visits.
Apply principles of population health management to identify patients with uncontrolled chronic conditions and rising risk indicators and refer to the Community Care Manager.
Provide care coordination services for patients requiring chronic care management.
Ensure that appropriate patients receive annual physical exam and/or annual health risk assessment (HRA) and complete required documentation.
Evaluate and refer patients to the Community Care Manager when acuity changes.
Follow treatment plans as written by the provider or Community Care Manager.
Assess patients in their home environment and assist the IDT in evaluating home needs to facilitate self‑management skills.
Lead IDT discussion on home management, including facilitation of home care referrals.
Facilitate discussion with patients and family members on advance directives.
Link patients with community resources such as prescription assistance.
Assist patients in navigating social and health services, including enrollment in social security, Medicaid, Medicare, and other insurance plans.
Assess and address patients’ safety needs in the home (e.g., fall risk) and order equipment to promote independence.
Assist with medication self‑management, such as setting up medication boxes.
Refer patients or families to community resources for housing or treatment and follow through to ensure service efficacy.
Educate and aid family members in supporting the patient with chronic illness and end‑of‑life practices.
Interview clients about activities of daily living to determine needs and link with community resources.
Review and update the provider and Community Care Manager on patients’ living conditions and ability to adhere to the plan of care.
Assess, monitor, and evaluate the patient’s progress in the home relative to treatment goals.
Document findings in the health care record following system‑approved protocols.
Collect data, maintain records, and utilize assessment tools related to patient care and wellness practices.
Coordinate access with primary and specialty providers, ensuring necessary records and documentation of referrals are completed and reconciled.
Educate patients on resources for primary and acute care, as well as alternative community programs that promote sound health, lifestyle, and well‑being.
Schedule timely and appropriate office and follow‑up visits with health care providers such as dentists, public health staff, social services, or outreach workers.
Work independently with minimal supervision.
Perform community outreach activities as assigned.
Requirements
Licensed Practice Nurse (LPN), Certified Medical Assistant (CMA), or trained Patient Care Assistant (PCA) with 2–3 years of acute care and/or ambulatory practice experience.
Prior experience working with care managers from an acute care setting or health insurance/payer entities preferred.
Excellent verbal and written communication skills and strong organizational skills.
Competency in electronic medical records desirable.
Bi‑lingual ability preferred (market specific).
Additional Information
Who We Are: LifeBridge Health is a dynamic, purpose‑driven health system redefining care delivery across the mid‑Atlantic and beyond, anchored by our mission to “improve the health of people in the communities we serve.” Join us to advance health access, elevate patient experiences, and contribute to a system that values bold ideas and community‑centered care.
What We Offer: Impact: Join a team that values innovation and outcomes, delivering life‑saving care to our youngest and most vulnerable patients. Growth: Opportunities for professional development, including tuition reimbursement and foundational skills for neonatal critical care leadership and advanced certification. Support: A culture of collaboration with resources like unit‑based practice councils and advanced clinical education support, improving workflow efficiency and patient outcomes and allowing you to work at the top of your license. Benefits: Competitive compensation (including overtime, shift differentials, premium pay, and bonuses may apply), comprehensive health plans, free parking, and wellness programs.
Why LifeBridge Health? With over 14,000 employees, 130 care locations, and two million annual patient encounters, we combine strategic growth, innovation, and deep community commitment to deliver exceptional care anchored by five leading centers in the Baltimore region.
LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression. LifeBridge Health does not exclude people or treat them differently because of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.