Value Based Care Coordinator

Joseph T Sherrel MD PA; Lake City (FL); On-site; USD 42,000 - 68,000; Full time

Job summary

North Florida Pediatrics is seeking a Care Coordinator to support patient communication, medication questions, refills, referrals, and lab/test result updates at the request of the clinician. The role also backs floor nursing, escorts patients, and ensures accurate vitals entry in the EHR, with vaccines administered per Chief Medical Officer and AAP guidelines.

You will work to identify high-risk rural patients, coordinate care across clinics, mobile units, telehealth, and specialists; conduct

Qualifications

• Certification – CMA, LPN, RN or a degree in healthcare administration or social work
• Experience – 1 to 3 years of clinical or outpatient primary care
• Technical Skills – familiarity with EHR systems and population health platforms

Responsibilities

• Identify high-risk or chronically ill patients in rural populations who need closer monitoring
• Bridge gaps between local primary care clinics, mobile health units, behavioral health tele hubs, and regional specialists
• Conduct regular check-ins between clinical visits to keep patient care plans on track and reduce emergency room usage
• Utilize electronic health records (EHRs) and health information exchanges (HIEs) to track quality metrics and close care gaps across disparate rural settings

Skills

Microsoft Outlook

Adobe

Education

CMA/LPN/RN or healthcare admin/social work degree

Job description

Supervisory Responsibilities:None, unless assigned by the Care Coordination Manager

Level of Access:Level I

Job Summary

At North Florida Pediatrics, our patients and their parents are our number one priority. Care Coordinators will provide and facilitate clear and timely communication to patients with medication questions and physician authorized prescription refills, referral processing, and updating patients with lab and test results at the request of the clinician. Care coordinators will also operate as back up to the floor nursing staff assisting in covering lunches, breaks, and call offs at the instruction of the Care Coordination Manager or Chief Medical Officer. Other responsibilities include escorting the patient and parent to the assigned room, taking accurate vitals, uploading medical history and vitals into the EHR, provide vaccines to the pediatric patients according to the standard put in place by the Chief Medical Officer and the American Academy of Pediatrics, running basic tests/swabs if needed, and provide excellent bedside manner. Leads will also be given special tasks assigned by their manager.

Essential Job Functions

General Summary

Manages patient care across rural networks to improve health outcomes, reduce avoidable costs, and shift clinics toward value-based payment models from fee-for-service models.

Essential Job Functions

• Patient Stratification: Identifying high-risk or chronically ill patients in rural populations who need closer monitoring and intensive management.
• Care Coordination: Bridging gaps between local primary care clinics, mobile health units, behavioral health tele hubs, and regional specialists.
• Preventive Outreach: Conducting regular check-ins between clinical visits to keep patient care plans on track and reduce emergency room usage.
• Data Integration: Utilizing electronic health records (EHRs) and health information exchanges (HIEs) to track quality metrics and close care gaps across disparate rural settings

Knowledge, Skills, and Abilities

• Electronic Mail Software: Email software, Microsoft Outlook
• Database user software: Adobe

Knowledge, Skills, and Abilities

• Certification – CMA, LPN, RN or a degree in healthcare administration or social work
• Experience – 1 to 3 years of clinical or outpatient primary care
• Technical Skills – familiarity with EHR systems and population health platforms

Knowledge, Skills, and Abilities

• Certification – CMA, LPN, RN or a degree in healthcare administration or social work
• Experience – 1 to 3 years of clinical or outpatient primary care
• Technical Skills – familiarity with EHR systems and population health platforms

Interpersonal Skills – Strong Verbal Communication, organization, and empathy to guide patients through complex health systems.

Physical Requirements

• Travel:Must have reliable transportation to work and be able to travel if needed within the region to other offices.
• Seeing: Must be able to see well enough to read emails, documents, reports, etc.
• Hearing: Must be able to hear well enough to communicate with other staff, clients, vendors, etc. Must be able to hear well enough to assess blood pressure manually using a stethoscope
• Standing/Walking: Must be able to move about the office for prolonged periods of time, including up and down stairs
• Climbing/stooping/kneeling: Must be able to stoop or kneel to pick up items, assist parents and children in performing necessary tasks (removing shoes, stepping onto the scale, assuming the correct position for height assessment, etc)
• Lifting/pulling/pushing: Must be able to lift up to 50 pounds
• Touching/grasping/feeling: Must be able to type and perform technical tasks

Working Conditions: Normal working conditions absent extreme factors

Note: The statements herein are intended to describe the general natures and level of work being performed but are not to be seen as a complete list of responsibilities, duties, and skills required of personnel so classified. Also, they do not establish a contract for employment and are subject to change at the discretion of the employer.