Care Coordinator

Millennium Physician Group; Jacksonville (FL); On-site; USD 26,000 - 39,000; Full time

Benefits offered by this job

Health, Dental, Vision Insurance

401(K) Retirement Plan with Matching

Paid Time Off

Floating Holidays

Employee Assistance Program (EAP)

Job summary

Millennium Physician Group is seeking a Care Coordinator to support the RN Care Manager in delivering coordinated outpatient care. You will implement care plans, review charts for gaps, and track referrals, tests, and follow-ups across primary care, specialists, and community partners.

The role emphasizes patient outreach, education on chronic disease management, and accurate documentation in the EHR. A CMA and BLS are preferred, with strong communication and organizational skills and the

Qualifications

• Certified Medical Assistant (CMA) with strong clinical knowledge.
• Minimum of three years in healthcare settings such as physician practice or outpatient clinic.
• Proficient with electronic health records (EHR) systems.

Responsibilities

• Support the RN Care Manager in implementing and monitoring individualized care plans.
• Conduct chart reviews to identify gaps and preventive care opportunities.
• Track referrals, follow-ups, and care plan objectives across multiple care settings.
• Coordinate care across providers, hospitals, SNFs, home health, and community resources.
• Perform patient outreach and engagement to address barriers to care.

Skills

Care coordination

Population health

Communication skills

EHR proficiency

Time management

Independent worker

Bilingual

Education

Certified Medical Assistant (CMA)

BLS certification

Tools

EHR software

Job description

Job Description SummaryThe Care Coordinator works under the direction of the RN Care Manager and partners with primary care providers, patients, caregivers, and interdisciplinary healthcare teams to support care management activities in the outpatient setting.This role is responsible for assisting with care coordination, transitions of care, chronic disease management, patient outreach, resource navigation, and clinical documentation to improve patient outcomes, reduce avoidable hospital utilization, and enhance the overall patient experience.This position is ideal for a Certified Medical Assistant (MA) with strong clinical knowledge, excellent communication skills, and a passion for patient-centered care.How will you make an impact & RequirementsCare CoordinationSupport the RN Care Manager in implementing and monitoring individualized care plans.Conduct routine chart reviews to identify care gaps, preventive care opportunities, and patient needs.Track referrals, follow-up appointments, diagnostic testing, and care plan objectives.Coordinate care across primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community organizations.Collaborate with interdisciplinary team members to ensure continuity of care.Patient Outreach & EngagementConduct telephonic outreach to patients and caregivers.Identify barriers to care including transportation, medication access, financial concerns, health literacy, and social determinants of health.Encourage participation in preventive care and chronic disease management programs.Build strong, trusting relationships with patients and caregivers.Transitions of CareSupport patients following hospitalizations, emergency department visits, or skilled nursing facility stays.Assist with post-discharge follow-up, appointment scheduling, medication reconciliation support, and care coordination activities.Coordinate community resources, services, and equipment needed to support successful recovery and ongoing care.Communicate critical patient information to providers and care team members to facilitate timely interventions.Patient EducationReinforce provider-directed education related to:Chronic disease managementMedication adherencePreventive health measuresSelf-management strategiesCommunity resources and support programsConnect patients with prescription assistance programs, transportation resources, support services, and community-based organizations.Documentation & Record ManagementMaintain accurate and timely documentation within the electronic health record (EHR).Obtain and manage external medical records, discharge summaries, consult notes, and test results.Track patient outreach efforts, care management activities, quality metrics, and outcomes.Resource Coordination & AdvocacyAssist patients in accessing clinical, behavioral health, social, and community resources.Serve as a patient advocate while promoting patient-centered care.Escalate clinical concerns to the RN Care Manager and providers as appropriate.Maintain current knowledge of local, state, and federal community resources.QualificationsCurrent Medical Assistant certification.BLS certification preferred.ExperienceMinimum of three (3) years of healthcare experience in a physician practice, outpatient clinic, care management, population health, case management, transitional care, home health, or a related healthcare setting preferred.Experience supporting chronic disease management and high-risk patient populations preferred.Proficiency with electronic health record (EHR) systems required.Knowledge, Skills & AbilitiesStrong organizational and time-management skills.Excellent verbal and written communication abilities.Ability to effectively engage patients and caregivers.Knowledge of care coordination, transitions of care, and population health principles.Understanding of chronic disease management and preventive care strategies.Strong documentation and computer skills.Ability to work independently while collaborating effectively with interdisciplinary teams.Bilingual skills are a plus.About Millennium Physician Group:Formed in 2008 and headquartered in Fort Myers, Florida, with offices in Florida, North Carolina, Georgia, and Texas, Millennium Healthcare is the largest independent physician group in the state of Florida and one of the largest in the United States. At Millennium Physician Group, our employees are the foundation of our success. Our promise is to provide you with the tools to do your job successfully, as well as providing a team atmosphere that empowers you to seek better ways to deliver care to our patients and their families. We also promise to care for you as an individual and help you grow in your role.What We Offer:Health, Dental, and Vision Insurance401(K) Retirement Plan with MatchingShort & Long-Term DisabilityEmployer-Paid Life InsurancePaid Time Off, Floating Holidays, and Paid Major HolidaysEmployee Assistance Program (EAP)and much more!How to Apply:ARE YOU READY TO JOIN OUR TEAM? We understand your time is valuable, and that is why we have a very quick and easy application process. If you feel that you are right for this position, please fill out our initial 3-minute, mobile-friendly application so that we can review your information. We look forward to meeting you!Compensation Range:$19.00to$28.50The 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.