Patient Care Coordination Manager

Inova Health; Falls Church (VA); Remote; USD 90,000 - 120,000; Full time

Job summary

Inova Health's Center for Personalized Health in Falls Church, VA is seeking a Patient Care Coordination Manager. The role is remote with on-site training required for the first three months and follows a Monday–Friday schedule from 8:00 a.m. to 4:30 p.m.

You will oversee complex care plans, advocate for patients, coordinate referrals, and guide families. Work with a multidisciplinary team to improve outcomes across the continuum of care.

Qualifications

• 3 years of progressive experience coordinating patient care and population health programs.
• Bachelor's in social work (BSW) or related field.
• BLS certification required at start.

Responsibilities

• Identify patient care opportunities and determine eligibility for treatments with the care team.
• Develop individualized care plans, facilitate referral processes and patient advocacy.
• Follow workflows in health information systems to track care across the continuum.
• Partner with community organizations to improve care transitions.
• Provide referral/transition support tailored to each patient.
• Educate patients and families about options, benefits, and self‑care.
• Perform other duties as assigned.

Skills

BLS Certification

Education

Bachelor's degree in Social Work (BSW) or related field

Job description

Inova Center for Personalized Health | Patient Care Coordination Manager | M-F (8am - 4:30pm)

Remote (On-site for first three months of training required)

The Manager of Patient Care Coordination facilitates and oversees the complex care plan and delivery of healthcare services for patients throughout the continuum of care. Acts as an advocate for the welfare and appropriate utilization of services for patients. Provides effective and timely referral management support to patients based on individualized needs. Serves as an advisor by providing emotional support, counseling, clinical education, resources and expert guidance to patients and families to promote their ability to understand and participate meaningfully in the healthcare process and personal decision making.

Job Responsibilities

• Identifies appropriate patient care opportunities for patients and determines patients' eligibility for prevention and diagnostic/clinical treatments. Collaborates with the multidisciplinary team to address patient questions about the care process and treatment options.
• Develops individualized patient care for patients seeking treatment by facilitating appointment scheduling, assisting with referral the process and providing information and advocacy to patients throughout care process.
• Follows the workflows required by the health information systems used to identify, monitor and document the care management of patients through the entire healthcare continuum including primary, secondary and tertiary care.
• Works in partnership with community-based organizations to improve the continuum of care for specific patient populations.
• Provides effective and timely referral/transition management support to patients based on individualized needs.
• Serves as a Liaison to community services for individuals looking for screening, diagnostic treatment and/or support services.
• Provides seamless transitions, utilizing the entire continuum of care, by designing and implementing a transitional plan that facilitates patients' movement to the next level of care.
• Educates patients, families, caregivers and members of the healthcare delivery team regarding treatment options, community resources, insurance benefits, self‑care management and other matters to facilitate timely/informed decision making throughout all phases of the continuum of care.
• Performs other duties as assigned.

Required Qualification

• Certification - Basic Life Support (BLS) - Upon Start
• Licensure - N/A
• Experience - 3 years of progressive experience with care or disease management to include coordinating patient care and population health programs.
• Education - Bachelor's in social work (BSW) or bachelor's in health, human social services, or related field.

Preferred Qualification

• Certification - Basic Life Support (BLS) - Upon Start + Certified Dementia Practitioner (CDP) certification required within one year of hire
• Experience - at least three years of patient care coordination experience; knowledge of commercial insurance, Medicare, and Medicaid; and preferably three or more years of experience in adult care or geriatrics