Collaborative Care Coordinator

Alabama Primary Health Care Association; Montgomery (AL); On-site; USD 90,000 - 110,000; Full time

Job summary

Alabama Primary Health Care Association (APHCA) seeks a Care Coordinator to support comprehensive care coordination activities across Alabama. The role partners with FQHCs, RHCs, and community providers to identify gaps, engage patients, and ensure timely follow-up of referrals.

The ideal candidate is organized, proactive, and outcomes-focused with experience in care coordination and patient engagement, able to serve diverse populations while maintaining confidentiality and professionalism.

Qualifications

• ADN or Practical Nursing Certificate from an accredited institution.
• Current, unrestricted Alabama or compact state nursing license.
• Minimum of five (5) years of clinical healthcare experience.
• Experience in patient care coordination, case management, or care management activities.
• Experience collaborating with diverse stakeholders across healthcare organizations and community partners.

Responsibilities

• Identify care gaps and monitor open referrals using care coordination platforms.
• Engage patients and families to assess needs and facilitate access to care and resources.
• Develop individualized patient goals and action plans and monitor progress.
• Coordinate appointments and referrals with primary care providers, specialists, and behavioral health providers.
• Provide education and guidance to patients and families for informed health decisions.
• Collaborate with multidisciplinary teams to ensure coordinated, patient-centered care.

Skills

Organizational skills

Planning

Communication skills

Team collaboration

Multitasking

Education

Associate Degree in Nursing (ADN)

Practical Nursing Certificate

Bachelor of Science in Nursing (BSN)

Tools

MS Office

EHR systems

Job description

Position Summary

At the Alabama Primary Health Care Association (APHCA), we believe stronger communities begin with stronger health centers. As a nonprofit professional association, we champion the operational, clinical, and financial success of community health centers across Alabama. We are a catalyst for high performance, driving impact through training, quality improvement, and innovative health technology services.

The Care Coordinator is responsible for supporting comprehensive care coordination activities that promote high-quality, patient-centered care and sustainable healthcare delivery across Alabama. Working in partnership with Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), healthcare providers, and community partners, the Care Coordinator will leverage care coordination and population health platforms to identify care gaps, facilitate patient engagement, support preventive care initiatives, and ensure timely follow-up of referrals through closed-loop referral processes.

The ideal candidate is a highly organized, proactive, and results-driven healthcare professional with experience in care coordination, patient engagement, and interdisciplinary collaboration. This individual will possess strong communication skills, demonstrate a commitment to improving health outcomes, and effectively support patients from diverse backgrounds in navigating the healthcare system and achieving their health goals.

Essential Duties and Responsibilities

Care Coordination

• Utilize care coordination and population health management platforms to identify care gaps, monitor open referrals, and prioritize patient outreach activities.
• Engage patients and families to assess needs, address barriers to care, and facilitate access to appropriate healthcare and community-based resources.
• Develop individualized patient goals and action plans, monitor progress, and support self-management strategies.
• Coordinate appointments and referrals with primary care providers, specialists, behavioral health providers, and community partners.
• Provide education, resources, and guidance to patients and families to support informed healthcare decision-making.
• Collaborate with multidisciplinary healthcare teams to ensure coordinated, patient-centered care and effective communication regarding patient needs and treatment plans.
• Maintain strict adherence to patient confidentiality, privacy regulations, and organizational policies while demonstrating compassion and professionalism in all interactions.

Data Quality and Reporting

• Utilize integrated care management, care coordination, and patient engagement platforms to support patient outreach and care management activities.
• Support workflows designed to improve patient engagement, referral management, transitions of care, and closure of preventive and chronic care gaps.
• Coordinate activities that strengthen collaboration among primary care, behavioral health, specialty care, hospital systems, and community-based organizations.
• Accurately document care coordination activities, patient interactions, interventions, and outcomes in accordance with program requirements.
• Develop and implement patient outreach campaigns to promote preventive screenings, follow-up care, and health maintenance activities.
• Monitor and report on quality metrics across multiple payers related to care coordination activities, care gap closure, and referral completion.

Required Qualifications

• Associate Degree in Nursing (ADN) or Practical Nursing Certificate from an accredited institution.
• Current, unrestricted Alabama or compact state nursing license.
• Minimum of five (5) years of clinical healthcare experience.
• Demonstrated experience in patient care coordination, case management, or care management activities.
• Experience collaborating with diverse stakeholders across healthcare organizations and community partners.
• Strong organizational, planning, facilitation, and communication skills with exceptional attention to detail.
• Proven ability to effectively manage multiple priorities, coordinate competing demands, and meet deadlines in a dynamic healthcare environment.
• Proficiency in Microsoft Office Suite and electronic health record (EHR) systems.
• Ability and willingness to travel throughout Alabama as required.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) from an accredited institution.
• Experience serving as a Care Coordinator, Case Manager, Population Health Coordinator, or in a similar healthcare role.
• Experience working with FQHCs, rural healthcare organizations, community mental health centers, hospitals, and community-based service providers.
• Knowledge of health information exchange (HIE) systems, care coordination platforms, and population health analytics tools.
• Experience supporting value-based care, quality improvement, or population health initiatives.
• Experience and awareness of national Patient Centered Medical Home standards through The Joint Commission and National Committee for Quality Assurance.

Knowledge, Skills, and Abilities

• Knowledge of healthcare operations, care delivery models, care coordination best practices, and healthcare technology systems.
• Understanding health-related social needs and community resource navigation.
• Ability to build and maintain collaborative relationships with patients, providers, and community partners.
• Strong interpersonal, problem-solving, and critical-thinking skills.
• Exceptional written and verbal communication skills.
• High level of accuracy, professionalism, and attention to detail.
• Demonstrated computer and related software use skills, including but not limited to MS Office, electronic health record systems, quality reporting, and care coordination and management software.
• Ability to work independently while contributing effectively within a team-oriented environment.
• Commitment to delivering high-quality, patient-centered care and improving health outcomes.

Success Measures

• Improvements in preventive and chronic care gap closure rates.
• Timely completion and closure of referrals through closed-loop referral processes.
• Increased patient engagement and successful completion of outreach activities.
• Accurate and timely documentation of care coordination activities.
• Effective collaboration with healthcare providers, community partners, and participating organizations.
• Achievement of program-specific quality, performance, and reporting objectives.

The Details

Full-time, in-office role (Monday–Friday, 8:00 am – 4:30 pm) in Montgomery, AL.

Annual salary: $100,000

Comprehensive hiring process is designed to ensure mutual fit and long-term success.

Why Join APHCA?

You’ll be part of a mission-driven team committed to improving healthcare access and outcomes across Alabama. Here, your work matters—every detail you manage helps health centers focus on what they do best: caring for people.

Recruitment Process

Initial Screening Call: initial 15-minute virtual or telephone call to review candidate experience/alignment with position requirements

Manager Interview: Onsite interview related to candidate experience and competencies, skills application to job role, benefit review, etc., with the position supervisor

Team Interview: Onsite interview with the APHCA team to review organizational culture, team expectations, and dynamics

CEO Interview: Based on team interview recommendations, final conversation with APHCA CEO to review overall performance expectations, cultural fit, and values alignment for long term success and satisfaction for candidate and APHCA team (often scheduled on the same day as team interview).