Pediatrics Care Coordinator

MAJOR FUNCTION:

The Pediatric Care Coordinator is responsible for facilitating the coordination of comprehensive, patient-centered medical, behavioral health, dental, and preventive healthcare services for pediatric patients, with a primary emphasis on identifying and closing gaps in care. Working collaboratively with pediatric providers, nursing staff, dental care coordinators, behavioral health professionals, population health staff, and community partners, the Pediatric Care Coordinator supports the delivery of timely, evidence-based preventive services and improved pediatric health outcomes.

The position plays a critical role in advancing organizational performance on applicable Healthcare Effectiveness Data and Information Set (HEDIS), Health Resources and Services Administration (HRSA) Uniform Data System (UDS), and payer-specific pediatric quality measures. Through proactive patient outreach, care-gap identification, appointment coordination, caregiver education, and systematic follow-up, the Pediatric Care Coordinator assists the pediatric team in ensuring that children receive recommended immunizations, well-child visits, growth assessments, weight-related counseling, oral healthcare, developmental services, and other age-appropriate preventive care.

Quality Standards:

• Professionalism
• Positivity
• Productivity
• Promptness
• Kindness

Job Duties include, but not limited to (subject to change):

Essential Duties and Responsibilities

• Pediatric Preventive Care and Care-Gap Management

• Identify pediatric patients with overdue or outstanding preventive, medical, behavioral health, dental, and developmental care needs through electronic health records (EHR), population health registries, and quality reporting tools.
• Collaborate with pediatric providers and clinical support staff to develop and implement targeted interventions to close identified gaps in care.
• Coordinate outreach to parents, caregivers, and legal guardians to schedule and facilitate recommended pediatric appointments and services.
• Prioritize patients according to age-specific preventive care requirements, clinical risk, overdue services, and organizational quality improvement priorities.
• Support completion of recommended well-child visits, preventive screenings, and follow-up appointments.
• Identify and help address barriers to accessing care, including transportation, appointment availability, language, health literacy, and social determinants of health.
• Pediatric Immunization Coordination

• Collaborate with the pediatric clinical team to improve childhood immunization completion rates, with particular emphasis on ensuring children receive recommended immunizations by their second birthday.
• Identify children approaching their second birthday who have incomplete immunization records or outstanding recommended vaccines.
• Coordinate caregiver outreach, immunization appointments, and follow-up activities to support timely vaccine administration.
• Review EHR and available immunization registry information to identify potential documentation gaps or immunizations administered by outside providers.
• Assist clinical staff with reconciling immunization histories and obtaining external vaccination documentation.
• Partner with providers and nurses to address caregiver questions, concerns, and barriers to vaccine completion, referring clinical questions to licensed professionals.
• Monitor immunization care gaps and report progress toward pediatric vaccination performance goals.
• Weight Assessment, Nutrition, and Healthy Lifestyle Coordination

• Support the pediatric team in ensuring patients receive recommended age-appropriate growth and weight assessments.
• Identify eligible children and adolescents with incomplete body mass index (BMI) percentile documentation or outstanding nutrition and physical activity counseling requirements.
• Coordinate appointments and follow-up to support completion of BMI percentile assessment and appropriate counseling for patients in applicable quality-measure age groups.
• Collaborate with pediatric providers, nursing staff, dietitians, and other appropriate professionals to connect patients and families with nutrition, physical activity, and healthy lifestyle resources.
• Assist with referrals for additional nutritional, weight management, or specialty services when ordered or recommended by clinical providers.
• Monitor documentation and completion of eligible weight assessment and counseling services in accordance with applicable HEDIS and UDS specifications.
• Pediatric Medical and Behavioral Health Coordination

• Facilitate communication and coordination among pediatric primary care providers, behavioral health professionals, specialists, families, and community-based organizations.
• Identify and facilitate follow-up for children with outstanding behavioral health screenings, referrals, or recommended services.
• Support continuity of care following emergency department visits, hospitalizations, or specialty care encounters when appropriate.
• Escalate urgent clinical concerns, abnormal findings, and identified patient safety risks to the appropriate licensed clinical professional.
• HEDIS, UDS, and Pediatric Quality Improvement

• Support the organization's performance improvement strategies for applicable pediatric HEDIS, UDS, and payer-specific quality measures.
• Maintain current working knowledge of assigned pediatric quality measures, age eligibility criteria, required services, and documentation standards.
• Utilize EHR registries, population health dashboards, and care-gap reports to identify patients requiring intervention.
• Partner with the Quality and Population Health teams to monitor patient-level care gaps and measure performance.
• Implement targeted outreach strategies based on upcoming measure deadlines, patient risk, and identified performance opportunities.
• Assist with validation and reconciliation of clinical information to support accurate reporting of completed services.
• Participate in quality improvement initiatives, including workflow optimization, Plan-Do-Study-Act activities, and evaluation of intervention effectiveness.
• Communicate trends, barriers, and opportunities for improvement to pediatric leadership and the Population Health team.
• Patient and Family Engagement

• Build trusting, respectful relationships with pediatric patients, parents, caregivers, and legal guardians.
• Provide culturally responsive, linguistically appropriate education concerning preventive care, routine pediatric visits, and available healthcare resources.
• Use motivational interviewing and patient engagement techniques, within the scope of the position, to encourage participation in recommended healthcare services.
• Assist caregivers with understanding recommended follow-up services and navigating healthcare appointments.
• Respect patient and family preferences while promoting shared decision-making with the appropriate clinical professionals.
• Coordinate access to community-based resources that address identified social and healthcare access needs.
• Documentation, Communication, and Collaboration

• Document patient outreach, care coordination activities, appointment outcomes, caregiver communications, and unresolved barriers accurately and promptly in the designated EHR or tracking system.
• Maintain accurate records of assigned patients, open care gaps, referrals, and follow-up activities.
• Communicate care coordination needs and unresolved issues to the appropriate pediatric care team members.
• Participate in pediatric team huddles, population health meetings, and quality improvement discussions.
• Maintain patient confidentiality and comply with HIPAA, organizational policies, and applicable privacy standards.
• Complete required training and participate in professional development activities.
• Perform other related duties as assigned.

Minimum Qualifications

Education

• High school diploma or GED required.
• Completion of an accredited or recognized Medical Assistant training program, or equivalent relevant healthcare experience, preferred.
• Associate degree in healthcare, public health, human services, or related field preferred but not required.
• Medical Assistant certification (CMA, RMA, or equivalent) preferred but not required.

Experience

• Minimum of two years of experience as a Medical Assistant, Care Coordinator, Patient Navigator, Community Health Worker, or in a comparable healthcare support position preferred.
• Experience working in pediatric primary care, family medicine, or community health is strongly preferred.
• Prior experience conducting patient outreach, coordinating appointments, managing referrals, or supporting preventive health initiatives preferred.
• Experience working with electronic health records and patient registries is strongly preferred.
• Familiarity with HEDIS, UDS, and population health quality measures is desirable; training will be provided.