Millennium Physician Group is one of the largest comprehensive primary care practices in Florida, serving communities through a value-based care model focused on improving patient outcomes and enhancing the healthcare experience. As part of Mosaic Health, MPG is committed to delivering coordinated, patient-centered care while partnering with health plans, providers, and community organizations to improve the health of the populations it serves.
Job Description Summary
The Care Coordinator works under the direction of the RN Care Manager and in collaboration with primary care providers, patients, caregivers, and interdisciplinary team members to support care management activities in the outpatient setting. This role assists with care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, and documentation to improve patient outcomes, reduce avoidable utilization, and enhance the patient experience.
The Care Coordinator MUST be a Licensed Practical Nurse (LPN) or an experienced Medical Assistant (MA) with strong clinical knowledge and care coordination experience.
How will you make an impact & Requirements
Program Goals
The Care Coordinator supports the following organizational goals:
Prevent unnecessary emergency department visits and hospital admissions.
Reduce 30-day hospital readmissions.
Improve communication and care coordination between Primary Care Providers (PCPs), specialists, and acute care settings.
Facilitate safe and effective transitions of care.
Support advance care planning discussions and documentation.
Assist patients and caregivers in identifying the most appropriate level of care following discharge.
Improve patient engagement, self-management, and adherence to care plans.
Essential Responsibilities
Care Coordination
-
Assist the RN Care Manager in implementing and monitoring individualized patient care plans.
-
Perform monthly patient chart reviews to identify care gaps, preventive care needs, and opportunities for intervention.
-
Monitor and track follow-up appointments, referrals, diagnostic testing, and care plan goals.
-
Coordinate services among primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community organizations.
-
Collaborate with the healthcare team to ensure continuity of care across settings.
Patient Outreach and Engagement
-
Conduct telephonic outreach to patients and caregivers as directed by the RN Care Manager.
-
Assess barriers to care, including transportation, medication access, financial concerns, health literacy, and social determinants of health.
Compensation Range:
$19.00
to
$28.50
The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.
Additional Information
Company: Vera Whole Health
Location: Florida
Salary: $19.00 – $28.50 per hour
Job ID:
Specialties: Care Manager
Required Licenses: RN, LPN/LVN
Experience Level: No Experience
