Clinical Care Coordinator

Sante Health System, Inc; Fresno (CA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

401k retirement plan

Paid time off

Advancement opportunities

Job summary

Sante Health System in Fresno, CA seeks a Clinical Care Coordinator in the Utilization Management department to coordinate care for Santé members post discharge and manage complex medical conditions to reduce readmissions.

You will collaborate with physicians, nurses, and care teams; perform initial and transitional assessments; develop care plans; ensure documentation and follow‑up; and maintain patient confidentiality while supporting quality improvement initiatives.

Qualifications

• Graduate of an accredited school of nursing.
• Minimum of two years of professional nursing experience in an ambulatory clinic or hospital setting.
• Must possess an active State Registered RN or LVN license.

Responsibilities

• Helps develop care management systems to document, monitor, track, and evaluate patient interventions across settings.
• Performs initial and transitional assessments and develops realistic care management plans.
• Applies nursing care management and utilization principles to ensure high‑quality, cost‑effective care.
• Maintains regular communication with PCPs, specialists, and community care providers to review patient progress.
• Coordinates post‑acute care services and follows up after hospital or ED encounters.
• Documents data in structured fields to support reporting requirements.
• Acts as a resource for quality improvement and liaises with patients and care teams.

Skills

Care coordination

Clinical assessment

Interdisciplinary collaboration

Patient communication

Documentation

Education

Registered Nurse (RN) license

Licensed Vocational Nurse (LVN) license

Job description

We are seeking to fill a key role of Clinical Care Coordinator within our Utilization Management department. This role will be responsible for coordinating care for Santé members post discharge from inpatient and Emergency Department (ED) care and/or with complex medical conditions with co- morbidities, and medication adherence in order to reduce ED utilization and inpatient readmissions and to improve health outcomes.

Qualifications

• Graduate of an accredited school of nursing.
• Minimum of two years of professional nursing experience in an ambulatory clinic or hospital setting.
• Must possess an active State Registered RN or LVN license.

CRITICAL SUCCESS FACTORS

Success Will Require Well-developed Competencies In These Areas

• Skill in operating a computer and basic office equipment.
• Ability to work effectively with others.
• Ability to communicate clearly. Knowledge of professional nursing theory and practice and patient care evaluation.
• Skill in applying and modifying the principles, methods and techniques of professional nursing to provide consultative services.
• Skill in identifying problems and recommending solutions.
• Skill in preparing and maintaining records, writing reports, and responding to correspondence.
• Skill in establishing and maintaining effective working relationships with patients, medical.

Essential Duties And Responsibilities

• Helps develop care management systems to document, monitor, track, and evaluate patient interventions across various organizations, inpatient, and primary care settings.
• Works with eligible patients to perform both initial and transitional assessments and develops realistic care management plans.
• Incorporates knowledge of nursing care management, levels of care, and utilization management principles to implement high-quality cost-effective care.
• Establishes a consistent communication and reporting schedule for periodic contact with the patient's PCP, specialists, community care providers and patients to review patient status and progress toward goals.
• Provides patient care coordination intervention and follow-up after interaction with health care system, e.g. inpatient, ED visit, outpatient specialty and in-home care services, etc.
• Communicates with social service staff and health care clinicians, about patient's care, utilization, and follow up plans, e.g. ED Care Facilitators, inpatient Care Coordinators, post-acute case managers, social workers, patient navigators, etc.
• Attends and presents case reviews at practice meetings, program meetings, and care coordination meetings.
• Ensures that appropriate data is documented in structured fields to support information tracking to meet the various reporting requirements.
• Acts as clinical resource person for program's quality improvement efforts.
• Acts as liaison between members, leadership, and community partners.
• Attend required meetings and participate in committees as requested.
• Participate in professional development and maintain professional affiliations.
• Maintain strictest patient confidentiality.
• Maintain strictest confidentiality.
• In the spirit of teamwork, employees are expected to follow any other job-related instructions and to perform any other job-related duties as requested.

About Sante Health System

Sante Health System is a Management Services Organization that serves multiple clients. "Sante" is the French word for health. Our name symbolizes our commitment to good health, progressive care, and leadership in our community.

Sante is one of the largest healthcare claims and billing management companies in Central California. The strength of Sante is the extraordinary network of physicians, health plans, and other health service providers it offers the people of our valley. Sante coordinates with physicians, health plans, hospitals, and ancillary providers to ultimately benefit the patient in a managed care environment. Sante Health System provides numerous client services such as billing, claims processing, contracting, credentialing, finance, human resources, information services, marketing/communications, physician services, practice management, provider relations, quality improvement, and utilization management.

Sante is celebrating over 30 years of dedicated service to the community. We deeply understand that we would not be successful in enhancing the quality of life of our patients without our incredible team. This is why we have created a work culture that is comprised of talented, driven, dedicated, innovative, and service-driven professionals. Being part of our team is like being part of a big family. Join our team and make Sante Health System your home away from home.

• We provide competitive pay, excellent benefits including medical, dental, vision, and life insurance, 401k retirement plan, paid time off, and opportunities for advancement.

www.santehealth.net