Care Management Coordinator

Description

The Care Management Coordinator supports the growth and effectiveness of Southeast Medical Group’s care management programs by connecting patients, providers, clinic teams, and care management partners.

This role combines referral coordination, patient engagement, care transitions, reporting, and process improvement. The Coordinator ensures eligible patients are identified, referred, and connected to the appropriate care management program while helping improve referral workflows and enrollment performance across multiple programs.

This position is well suited for an experienced Medical Assistant or LPN interested in expanding into Population Health, care management, and value-based care.

Requirements

Key Responsibilities

• Manage and process care management referrals through centralized queues and inboxes within Veradigm, eClinicalWorks (eCW), and other applicable systems.
• Review referrals for completeness and route eligible patients to the appropriate internal or external care management program.
• Communicate with providers and clinic teams to obtain missing information and facilitate timely referral completion.
• Engage patients when appropriate to explain available care management programs, confirm interest, and support enrollment.
• Support Advanced Primary Care Management (APCM) enrollment activities, including patient education, consent, documentation, and coordination.
• Obtain discharge summaries, hospital records, specialist documentation, and other clinical information needed to support care transitions and ongoing care management.
• Coordinate with providers, clinic staff, Population Health teams, and external partners to support continuity of care.
• Develop and maintain reports related to referral volume, outreach, enrollment, conversion rates, and program performance.
• Analyze referral and enrollment trends to identify barriers and opportunities to increase patient participation.
• Identify and implement improvements to referral, enrollment, documentation, and tracking workflows.
• Support the implementation and growth of new care management programs and initiatives.
• Educate and support clinic teams regarding referral criteria, workflows, and available care management resources.
• Build strong relationships with physicians, APPs, practice leadership, clinical staff, patients, and care management partners.
• As programs expand, support SPCP affiliate practices interested in developing or enhancing care management capabilities.
• Perform other duties as assigned.

Minimum Qualifications

• High school diploma or equivalent required; additional clinical education preferred.
• Current nationally recognized Medical Assistant certification or Licensed Practical Nurse (LPN) licensure required.
• Minimum 3 years of clinical healthcare experience, preferably in primary care.
• Experience working directly with patients, providers, and multidisciplinary healthcare teams.
• Experience using electronic health record systems; Veradigm and/or eClinicalWorks experience preferred.
• Strong computer skills and ability to work with patient lists, reports, and clinical data.
• Ability and willingness to travel approximately 50%.

Preferred Qualifications

• Experience in Population Health, care management, chronic care management, care coordination, transitions of care, or value-based care.
• Experience with patient enrollment, referral management, or clinical program operations.
• Experience reviewing and interpreting operational or clinical reports and performance metrics.
• Experience in a multi-site primary care organization or similar healthcare environment.

Prior Population Health experience is preferred but not required. This role provides a strong growth opportunity for an experienced clinical professional seeking to develop a career in Population Health and care management.

Knowledge, Skills & Abilities

• Strong clinical judgment and ability to recognize when concerns require escalation.
• Excellent patient, provider, and team communication skills.
• Ability to explain care management programs clearly and effectively.
• Strong organization, follow-up, documentation, and attention to detail.
• Ability to manage multiple referrals, programs, and priorities simultaneously.
• Ability to work independently and exercise sound judgment with limited supervision.
• Strong analytical and problem-solving skills with the ability to identify trends and improvement opportunities.
• Ability to build effective relationships and provide strong service to providers and clinic teams.
• Ability to adapt to changing priorities in a growing Population Health environment.
• Proficiency with electronic health records, Microsoft Office, and healthcare reporting tools.

Key Measures of Success

Success in this role includes:

• Timely and accurate processing of care management referrals.
• Improved referral-to-enrollment conversion.
• Increased patient participation in appropriate care management programs.
• Reliable referral and enrollment tracking and reporting.
• Improved clinic referral workflows and reduced referral leakage.
• Timely retrieval of records supporting transitions of care.
• Strong relationships with patients, providers, clinics, and care management partners.
• Identification and implementation of measurable process improvements.

Physical & Mental Requirements

• Ability to sit and/or stand for extended periods.
• Ability to operate standard office and computer equipment.
• Ability to travel between clinic and business locations.
• Ability to communicate effectively verbally and in writing.
• Ability to apply sound judgment and logical reasoning to routine and complex situations.
• Ability to manage multiple priorities in a fast-paced healthcare environment.

Equal Employment Opportunity

Southeast Primary Care Partners is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to any characteristic protected by applicable federal, state, or local law.