Chronic Care Coordinator

PanCare of Florida, Inc.

Chronic Care Coordinator at PanCare of Florida providing patient-centered, team-based care coordination. Ensuring safe medication use and connecting patients with essential resources while supporting chronic care management.

Posted 7/11/2026full-timeBlountstown • Florida • 🇺🇸 United StatesJuniorMid-Level💰 $0 - $20 per hourWebsite

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

High school diploma or equivalent required
Associate's degree in healthcare administration, social work, public health, nursing, or related field preferred
Minimum of two years of experience in healthcare, care coordination, case management, population health, community health, or medical office operations preferred
Knowledge of Medicare, Medicaid, and community resources
Familiarity with HEDIS, UDS, CCM, APCM, and value-based care initiatives
Strong organizational and time-management skills.
Excellent verbal and written communication skills
Ability to work independently and collaboratively within interdisciplinary teams
Proficiency with electronic health records and Microsoft Office applications
Ability to manage multiple priorities in a fast-paced environment

Benefits

Comp & perks

Health insurance
Dental insurance
Vision insurance
14 paid holidays
3 weeks of paid vacation per year
403(b) plan with a 6% employer match
3% base employer contribution

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Care ManagementPopulation HealthCase ManagementAppointment SchedulingRisk StratificationPatient EducationPerformance Metrics TrackingQuality ImprovementRegulatory ComplianceDocumentation

Soft Skills

Organizational SkillsTime-Management SkillsVerbal CommunicationWritten CommunicationTeam Collaboration