INTEGRATED CARE COORDINATOR

Description

MISSION, VISION, & VALUES

Our MISSION…to bring out the courage in others.

Our VISION…to be recognized as the market leader in operating provider-led, clinically-integrated networks of high quality, value-oriented services across the healthcare spectrum.

Our VALUES...Trust, Integrity, Teaching, Collaboration, Transparency, Innovation, Discipline.

JOB SUMMARY

The Integrated Care Coordinator is responsible for facilitating, coordinating, and assisting with 

essential services to support patient transitions through various care settings, including hospitals, 

transitional care facilities, long-term care or assisted living facilities, and private homes. This role 

encompasses coordination for all patient transitions, including internal transfers across Home 

Health, Hospice, Personal Care, or Palliative Care services.

Examine patients and review their medical histories.

•  Order, conduct, and interpret diagnostic tests, including blood tests and imaging.
•  Diagnose health conditions and illnesses, proposing treatment plans for chronic and infectious diseases.
•  Prescribe medications and manage patient treatment plans.
•  Maintain accurate patient records and scheduling.
•  Educate patients and family members about health conditions, treatments, and preventative practices.
•  Provide holistic oversight of patients’ health and wellness.
•  Promote healthy lifestyle practices and educate on disease prevention.
•  Participate in continuing education, research, and professional development.
•  Offer preventative care options, including alternative treatments such as trigger point injections and medical massage

RESPONSIBILITIES

•  Collaborate professionally with facility or agency staff, focusing on discharge planning and care transitions.
•  Interact face-to-face with patients, residents, and their families throughout their stay, coordinating healthcare and resources needed for transitions.
•  Educate residents and families on planned services and community resources.
•  Communicate and document relevant information, including Home Services, DME, 

Provider appointments, and community resources.

•  Populate resident data related to admission and discharge on designated forms or platforms.
•  Perform post-discharge outreach to ensure planned transitions are completed successfully and services are received.
•  Coordinate with post-acute care providers to ensure timely access to care after discharge or transfer.
•  Participate in meetings with internal and external staff to discuss procedures, outcomes, and quality improvement.
•  Availability: Monday through Friday, 8:00 AM - 5:00 PM, with availability for on-call as program needs require.

WORKING ENVIRONMENT

Primarily indoor work across assigned facilities, with travel required to multiple locations, 

including hospitals, other care facilities, and patient residences. Mileage for work-related travel 

may be reimbursed. Limited remote work may be available based on job requirements.

JOB RELATIONSHIPS

Supervised by: Executive Director

Workers Supervised: None

RISK EXPOSURE

Potential exposure to injury from falls, equipment burns, odors, and environmental contaminants, 

as well as infectious waste, diseases, and hazardous chemicals. May encounter emotionally upset 

patients or visitors.

LIFTING REQUIREMENTS

This role includes physical requirements such as sitting, writing/typing, pushing/pulling, lifting 

up to 25 pounds, seeing, speaking, walking, standing, driving, kneeling/stooping, hearing, and 

fine-motor skills

Requirements

QUALIFICATIONS

•  Minimum of two years of combined work experience in case coordination or related healthcare roles, including Nursing (RN or LPN), Social Work, Mental Health, Community Health, emergency services, Medical Assistance, Certified Nursing Assistance, or applicable healthcare experience.
•  Proven problem-solving skills with the ability to manage multiple tasks.
•  Skilled in collaboration, with interpersonal skills to handle family emotional stress and respect diverse lifestyles.
•  Cheerful disposition, with enthusiasm for teamwork and supporting team objectives.
•  Ability to make meaningful observations and write accurate, comprehensive reports.
•  Competency in medical record research, internet searches, spreadsheets, and word processing software.
•  Ability to assess and respond to the needs of patients and families in varied settings.
•  Strong organizational and time management skills.
•  Effective, professional communication skills.
•  Valid driver’s license and access to a vehicle.
•  Current license, certification, or registration in a related healthcare field as applicable

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