Summary

JOB SUMMARY:

The Community Care Coordinator works under the oversight of the Community Care Manager or Supervisor, to promote the health and welfare of assigned patients through face to face and/or phone outreach and e-mail communications. The Community Care Coordinator is a member of Interdisciplinary Team (IDT) caring for the patient in ensuring the patient’s individual needs are identified and addressed in a timely manner, act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family.

Accountable for contacting 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 for assigned patients including Post-hospital discharge and Annual Wellness Visits where appropriate Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to Community Care Manager accordingly 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) including completion of required documentation by payer contract Evaluates and refers patients to Community Care Manager, as appropriate, when acuity changes Follow treatment plans of patient as written by provider and/or Community Care Manager Where appropriate, assesses patient in the home environment and assist the IDT to evaluate the patient’s needs in their home to facilitate the patient’s ability to improve self-management skills. Leads the IDT discussion in home management of assigned patients including facilitation of home care referrals where appropriate Where appropriate, facilitate discussion with patient and family members on advance directives. Provides expertise in linking patients with community resources such as prescription assistance Assist patients in navigating social and health services such as enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans Assesses and assist patient’s safety needs in home, i.e. fall risk and order equipment where necessary to promote patient independence Assist with self-management of medication, i.e. setting up medication boxes if needed. Refer patient or family to community resources for housing or treatment to assist in recovery from chronic illness and following through to ensure service efficacy. Educate and aid family members to assist them in understanding, dealing with, and supporting the patient with a chronic illness and end of life practices Interview clients about activities of daily living to determine needs and link with community resources where appropriate Reviews and updates Provider and Community Care Manager of patients’ living conditions and ability to adhere to plan of care and coordinate treatment goals Assess, monitor, and evaluate, the patient’s progress in the home with respect to treatment goals. Documents findings in health care record following System approved protocols. Perform the tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices. Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled. Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle, and well-being. Schedule timely and appropriate office and follow-up visits at/with and or other health care providers such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients Be able to work independently with minimal supervision Community outreach activities as assigned

REQUIREMENTS:

Licensed Practice Nurse (LPN) or Certified Medical Assistant (CMA) or trained Patient Care Assistant (PCA) with 2-3 years acute care and/or ambulatory practice experience Preferably with experience working with care managers from acute care setting or health insurance and/or other payer entities. Good verbal and communication skills and organizational skills a must Competency in electronic medical records desirable Bi-lingual preferable (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 developing 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 both workflow efficiency and patient outcomes and allowing you to work at the top of your license.

Benefits: Competitive compensation (additional compensation such as overtime, shift differentials, premium pay, and bonuses may apply depending on job), 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: Sinai Hospital of Baltimore, Grace Medical Center, Northwest Hospital, Carroll Hospital, and Levindale Hebrew Geriatric Center and Hospital.

Our organization thrives on a culture of CARE BRAVELY—where compassion, courage, and urgency drive every decision, empowering teams to shape the future of healthcare.

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.