PanCare of Florida, Inc.

Care Coordinator

• Conduct patient outreach and engagement activities for assigned patient populations
• Assist patients in navigating healthcare services and overcoming barriers to care
• Coordinate care transitions following hospitalizations, emergency department visits, and specialty care encounters
• Facilitate communication among primary care providers, specialists, behavioral health providers, and community partners
• Monitor patient adherence to treatment plans and follow-up recommendations
• Assist patients with appointment scheduling and transportation arrangements as needed
• Participate in development and implementation of individualized care plans
• Assist with risk stratification and identification of patients requiring care management services
• Support enrollment and ongoing management of patients participating in CCM, APCM and RPM programs
• Monitor patients with chronic conditions and provide education on disease self-management
• Document care coordination activities in the electronic health record and care management platforms
• Collaborate with referral staff to address barriers preventing patients from receiving recommended services
• Screen patients for social needs, including food insecurity, housing instability, transportation needs, financial barriers, and utility assistance needs
• Connect patients to community resources and social service agencies
• Advocate for patients experiencing barriers that negatively impact health outcomes
• Support initiatives designed to improve HEDIS, UDS, and value-based performance measures
• Participate in outreach campaigns for preventive screenings and chronic disease management
• Assist with annual wellness visits and care gap closure activities
• Prepare reports and track performance metrics as assigned
• Document all patient interactions accurately and timely in the electronic health record
• Maintain patient confidentiality in accordance with HIPAA and organizational policies
• Complete required reports, registries, and care management documentation within established timelines
• Monitor assigned work queues and ensure timely resolution of patient needs
• Demonstrate commitment to organizational compliance and quality standards by following established policies and procedures, maintaining regulatory requirements, participating in quality improvement efforts, and reporting concerns through appropriate channels

Chronic Care Coordinator