Care Coordinator

Overview

Primary Accountability

The Concierge Care Coordinator serves as a dedicated healthcare navigator for patients enrolled in the CBHA Concierge Care Program. This position provides personalized support to patients with chronic conditions, complex care needs, or barriers to accessing healthcare services. The Concierge Care Coordinator acts as a single point of contact for assigned patients and assists with coordinating appointments, medications, referrals, insurance coverage, transportation, and other healthcare needs.

The role emphasizes proactive patient outreach, chronic disease support, and care coordination to improve patient outcomes, engagement, and overall healthcare experience. The Concierge Care Coordinator works closely with providers, nurses, patient benefits, pharmacy, referrals, and other departments to ensure that patients receive coordinated, timely care consistent with Patient‑Centered Medical Home (PCMH) principles.

Description of

Primary Responsibilities:

• Patient Navigation and Support
• Serve as the primary point of contact for assigned patients enrolled in the Concierge Care Program.
• Provide individualized support to help patients navigate healthcare services within CBHA.
• Conduct monthly outreach to assigned patients to assess health needs, barriers to care, and support adherence to care plans.
• Build strong relationships with patients to improve engagement, trust, and continuity of care.
• Coordinate healthcare activities for approximately 150-200 patients, depending on patient complexity and program needs.
• Care Coordination
• Serve as the primary point of contact for assigned patients enrolled in the Concierge Care Program.
• Provide individualized support to help patients navigate healthcare services within CBHA.
• Conduct monthly outreach to assigned patients to assess health needs, barriers to care, and support adherence to care plans.
• Build strong relationships with patients to improve engagement, trust, and continuity of care.
• Chronic Disease Support
• Provide basic education and support related to chronic disease management, including diabetes and hypertension.
• Assist patients in learning how to use home monitoring devices such as glucometers and blood pressure monitors. Monitor patient-reported health information and communicate concerns to the clinical care team when appropriate.
• Medication Coordination
• Support patients with medication-related questions and coordination with CBHA pharmacy.
• Assist patients in obtaining medications and understanding medication instructions.
• Insurance and Benefits Assistance
• Assist patients with maintaining active health coverage, including Medicaid and other insurance programs.
• Work collaboratively with Patient Benefits to support renewal applications and eligibility processes.
• Transportation and Access Support
• Assist patients with scheduling transportation to medical appointments when necessary.
• Coordinate with community transportation resources or CBHA services to support patient access to care.
• Patient Advocacy
• Identify barriers to care, including social determinants of health, and connect patients with appropriate resources.
• Advocate for patient needs within the healthcare system to ensure timely and appropriate care.
• Documentation and Reporting
• Document all patient interactions in the electronic health record and/or Azara Care Connect in accordance with CBHA policies.
• Maintain accurate records of patient outreach, care coordination activities, and follow-up needs.
• Participate in program data collection and reporting for quality improvement initiatives.
• Collaboration
• Work closely with providers, nurses, contact center staff, patient benefits, referrals coordinators, and pharmacy staff to ensure seamless patient support.
• Participate in care…