Medicare Care Coordination Specialist-ACO

Job Details

Job Location: Ridgeland, MS 39157

Position Type: Full Time

As a Medicare Care Coordination Specialist – ACO / Population Health, you’ll serve as a key support for Medicare members transitioning across care settings. You will help ensure patients receive timely follow‑up after hospital or emergency department visits, understand their care plans, and receive assistance navigating barriers that could lead to unnecessary readmissions or higher costs of care.

You’ll work closely with providers, care managers, hospitals, and community partners to help our Medicare members stay healthier, safer, and better supported—while also advancing Trust Care’s cost containment and quality goals under the ACO model.

In addition to the Medicare Care Coordination functions, the role will also support our Finance Department through processing of accounts payable invoices and processing of company credit card transactions and payments.

• Conduct timely outreach to Medicare members following hospital admissions, discharges, or emergency department visits.
• Confirm patient understanding of discharge instructions, medications, and follow‑up care needs.
• Ensure appropriate primary care or specialty follow‑up appointments are scheduled within recommended time frames.
• Identify early warning signs, gaps in care, or barriers that could increase risk for readmission and elevate concerns appropriately.
• Support medication reconciliation efforts by confirming access, adherence, and understanding of prescribed therapies.
• Assist Medicare members in navigating the healthcare system, including understanding when to use primary care, urgent care, or emergency services.
• Identify social and non‑clinical barriers such as transportation issues, food insecurity, lack of caregiver support, or financial concerns and help connect patients with appropriate resources.
• Collaborate with Trust Care providers, nurses, care managers, patient access teams, and external partners to support coordinated care transitions.
• Maintain accurate and timely documentation of outreach, patient interactions, and care coordination activities.
• Support ACO quality, utilization, and cost‑containment initiatives through consistent follow‑up and communication.
• Serve as a compassionate, reliable point of contact for Medicare members and their caregivers during care transitions.
• Coordinate and process vendor invoices using the appropriate software tool for coding and workflow approval on strict timelines.
• Manage vendor portals to ensure account balances are verified and accurate.
• Process and code charges to company credit cards.

• A genuine passion for helping Medicare patients navigate complex healthcare needs.
• Strong communication skills with the ability to build trust and rapport over the phone and in person.
• A calm, solutions‑focused approach to problem solving and patient support.
• Attention to detail and strong organizational skills.
• The ability to manage multiple patients, priorities, and follow‑ups effectively.
• A team‑first mindset and willingness to collaborate across departments.

• High school diploma or equivalent required.
• Prior experience in healthcare coordination, patient outreach, case management support, or population health preferred.
• Experience working with Medicare patients or value‑based care programs strongly preferred.
• Familiarity with hospital discharge processes, care transitions, or utilization management is a plus.
• Comfort using EMR systems, tracking tools, and standard office software.
• Knowledge of community resources, social services, or healthcare navigation is beneficial but not required.