Patient Care Coordinator

Job title: Care Coordinator

RHTP alignment: Community Health Navigator & Care Coordinator

Reports to: Practice Manager

Clinical collaboration: Nursing leadership and assigned providers

Position: Full time, 1.0 FTE

FLSA Status: Nonexempt

Work Schedule: Full time, 1.0 FTE, five days per week; occasional evening or weekend outreach assignments.

Work Location: On-site at assigned LRHC locations, with patient and community visits as assigned. This is not a remote position.

Position Objective

The Care Coordinator helps patients obtain and remain connected to coordinated, whole-person healthcare by addressing access barriers, organizing follow-up, and linking health and social services. Through LRHC’s Rural Health Transformation Program (RHTP) and the RIVER (Regional Integrated Vermont Enhanced Rural) Community Health Network, the position connects centralized services, clinics, Healthy at Home, mobile care, satellite access points, and community resources.

The role combines patient navigation, panel management, previsit planning, resource assistance, and ongoing outreach. Working with patients, caregivers, and interdisciplinary teams, the coordinator helps patients complete agreed next steps and brings unresolved needs to the appropriate staff. Duties reflect qualifications and training; clinical assessment, triage, treatment, and nursing care planning remain with authorized clinicians.

Patient Navigation and Care Coordination

Engage patients and caregivers to identify access barriers, priorities, and practical support needs. Collaborate with clinical staff on functional, social, transportation, medication access, and financial concerns.

Help patients navigate primary care, behavioral health, substance use treatment, pharmacy, dental, and enabling services. Explain access arrangements and facilitate handoffs to responsible staff.

Coordinate assigned patient follow-up across clinic, home, mobile, satellite, and telehealth services. Track agreed actions, appointment attendance, barriers, and connections to ongoing care.

Work with referral and diagnostic coordinators on appointment linkage and follow-through. Help patients overcome barriers to completing referrals or testing, and route unresolved clinical issues to the ordering team.

Support Healthy at Home and Advanced Primary Care Management (APCM) engagement, outreach, care transitions, and care management notifications under approved workflows.

Help patients and caregivers arrange additional support as health, independence, and care needs change. Coordinate with home health and other services consistent with the clinical plan and patient preferences.

Panel Management and Previsit Planning

Use EHR and approved care management reports with quality and clinical teams to identify patients due for preventive care, chronic condition follow-up, or other assigned services.

Conduct assigned outreach, schedule needed appointments, and document responses, declined services, barriers, and follow-up. Bring high-need patients to clinical team review.

Prepare visits by reviewing assigned chart information, obtaining outside records, and coordinating ordered labs, diagnostics, and preventive services under approved procedures.

Participate in panel reviews and interdisciplinary meetings. Track assigned actions and share patient information needed for coordinated follow-through.

Community Resources and Access Assistance

Maintain resource contacts and link patients to food, housing, transportation, childcare, prescription assistance, equipment, and other supports.

Help patients access insurance assistance, sliding fee discounts, benefits, and financial counseling. Coordinate applications and referrals through approved processes.

Follow up on resource referrals to learn whether assistance was obtained. Document unresolved needs and seek alternatives with patients and partners.

Coordinate with schools, caregivers, and community services as authorized. Attend designated community meetings and share service information.

Documentation and RHTP Improvement

Document outreach, needs, actions, referrals, and follow-up in approved systems. Follow consent, release, privacy, and secure information-sharing procedures.

Help standardize navigation across service settings. Participate in training and Lean or Plan-Do-Study-Act improvement activities.

Contribute outreach, linkage, barrier, and follow-up information to evaluation and the Rural Primary Care Capacity Index (RPCCI). Document grant-supported work under LRHC procedures.

Identify professional development needs with the Practice Manager. Perform other duties consistent with training, qualifications, and the role.

Working Relationships and Authority

Reports to the Practice Manager, who establishes work priorities, provides direct supervision, and coordinates performance management. Works with patients, caregivers, providers, nursing, Healthy at Home/APCM, Quality, administrative coordinators, and community resources to support navigation and reliable follow-through.

Partners with the Manager of Administrative Services and assigned referral, diagnostic imaging, and patient services staff on centralized access and coordination workflows. Coordinates support for mobile and community services with the Practice and Mobile Operations Manager through established workflows and the supervising Practice Manager.

Referral and diagnostic staff retain responsibility for assigned order and authorization workflows. Clinical assessment, triage, treatment, and nursing care planning remain with authorized clinicians. Escalate clinical concerns to nursing or providers and unresolved operational priorities to the supervising Practice Manager.

Education Experience and Abilities

Nursing, medical assisting, social work, psychology, human services, or related education preferred. Relevant primary care or community coordination experience will be considered.

Experience with patient navigation, medical office services, care coordination, or community resources preferred. Maintain applicable credentials for any separately assigned clinical duties.

Understanding of how health and social needs affect access. Ability to locate resources and build working relationships with service organizations.

Strong communication, interviewing, organization, and problem-solving skills. Motivational interviewing experience preferred. Respect for patient choice, dignity, and cultural differences.

Proficiency with EHR documentation, reports, office software, and approved care management tools. Ability to maintain accurate records and protect confidential information.

Ability to manage competing follow-up needs, work independently within assigned responsibilities, and seek supervision or clinical assistance when needed.

Indicators of Success

The Practice Manager, in collaboration with clinical leaders, will establish goals against baseline information for outreach, preventive follow-up, appointment and referral completion, resource connections, documentation, and patient experience. Clinical outcomes are shared team responsibilities.

Working Conditions and Acknowledgment

Work includes office and telephone duties, patient meetings, occasional local travel, and flexible outreach hours. Essential communication, record review, and coordination duties may be performed with reasonable accommodation.

Duties may evolve with organizational needs, consistent with qualifications and training.

Pay: $22.00 - $26.85 per hour

Expected hours: 40.0 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person