Care Coordinator

DISCLAIMER

Job descriptions are not meant to be all-inclusive, and the job itself is subject to change. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Summary

The Care Coordinator serves as the main point of contact for facilities and physicians participating in the High Needs REACH program. This role blends care transition functions with provider consulting responsibilities to ensure patients experience seamless care coordination, facilities achieve measurable performance improvement, and providers are engaged with data-driven insights. The Care Coordinator will work closely with post-acute facilities, physicians, patients, and internal PBACO teams to reduce readmissions, improve quality, and strengthen participant satisfaction.

This position requires strong communication skills, the ability to share and interpret data with stakeholders, and the clinical knowledge to support patients navigating their Medicare benefits. The role requires travel up to two times per month, including overnight stays, to meet with facilities and providers.

Essential Duties And Responsibilities

Care Coordination

• Monitor ADTs (admission, discharge, transfer feeds) to identify outlier information that may impact patient outcomes.
• Alert facilities or participating providers when relevant findings are identified.
• Encourage communication between facilities and participating providers to support collaborative decision-making.
• Promote provider engagement in care planning decisions, including the use of auxiliary services within the residence (e.g., therapy, ancillary support services).
  
  

Provider & Facility Engagement

• Serve as the primary liaison for High Needs REACH facilities and participating providers.
• Conduct monthly facility performance review meetings, presenting data and opportunities for improvement with measurable action items.
• Educate facility staff and providers on REACH program requirements, PBACO policies, and care coordination best practices.
• Perform targeted education visits with physicians and staff to drive adoption of policies and clinical initiatives.
  
  

Data & Reporting

• Share facility- and provider-level data with stakeholders, highlighting opportunities for improvement.
• Monitor and report on performance metrics such as readmissions, length of stay, transition timeliness, and patient satisfaction.
• Document all patient, provider, and facility interactions in designated platforms with 100% compliance.
• Piece together data from multiple sources and present tailored insights based on the audience (executives, providers, facility staff, or patients).
  
  

Program & Network Support

• Collaborate with internal PBACO teams (Data Analytics, Clinical Action Team, Population Health) to align care coordination with organizational goals.
• Identify facility-level trends or barriers impacting patient outcomes and escalate as needed.
• Promote and support the use of automation and technology for care coordination and data sharing.
  
  

Key Performance Indicators (KPIs)

Care Coordination & Outcomes

• ≥ 90% of patient transitions completed with documented PCP follow-up.
• ≥ 85% patient satisfaction with outreach.
• ≥ 10% annual reduction in preventable readmissions for High Needs REACH patients.
  
  

Facility & Provider Engagement

• 100% of assigned facilities have monthly performance review meetings documented with measurable improvement goals.
• ≥ 80% of participating facilities demonstrate improvement in at least one tracked metric (LOS, readmissions, or timeliness).
• ≥ 95% provider satisfaction with communication and support.
  
  

Operational Efficiency & Reporting

• ≥ 98% accuracy in documentation and reporting of patient transitions and facility metrics.
• 100% of reports and meeting documentation completed within 48 hours of interaction.
• ≥ 2 operational improvements implemented annually to enhance care coordination workflows.
  
  

Competencies

• Clinical Knowledge: Understanding of Medicare benefits, transitions of care, and post-acute continuum (SNF, HHA, rehab).
• Communication: Strong written/verbal skills for engaging patients, providers, and facility staff.
• Data Interpretation & Analytics: Strong Excel and analytic skills; ability to synthesize and piece together data from multiple sources to create actionable opportunities tailored to different audiences.
• Relationship Building: Develops trust with physicians, facility leaders, and patients.
• Problem-Solving: Identifies barriers to care and develops creative, patient-centered solutions.
• Technology Use: Comfortable with care coordination platforms and data-sharing tools.
  
  

Qualifications

• Education: Bachelor’s degree in Healthcare, Nursing, or Administration required; Master’s degree in a relevant subject preferred.
• Experience: ≥ 2 years in SNF, HHA, care management, or provider relations.
• Preferred: Prior ACO or value-based care experience, familiarity with High Needs populations.
• Technical Skills: Strong Excel and data analytic skills required; proficiency in Microsoft Office; familiarity with care coordination platforms (e.g., CarePort, Epic, or similar).
• License: Valid driver’s license; ability to travel up to two times per month with overnight stays.
  
  

Physical Demands

• Combination of office-based work, facility visits, and occasional patient interaction.
• May work at a computer for prolonged periods.
• May lift and/or move up to 10 pounds.
  
  

Supervisory Responsibilities

• This is not a supervisory role.