Care Coordination Specialist

2 weeks ago

Gainesville, Florida, United States Northeast Georgia Health System, Inc Full time

Job Category:

Behavioral Health, Counseling, and Clergy

Work Shift/Schedule:

8 Hr Morning - Afternoon

Northeast Georgia Health System is dedicated to enhancing the health of our communities.



About the Role:

Job Summary

This position provides a comprehensive range of support services for the Case Management team. The role involves assisting the RN Case Manager and Social Worker with discharge planning, continuum placement, communication with insurance providers, and data collection. Collaboration with physicians and other healthcare team members is essential to support patient care monitoring, coordination, and facilitation. The position aims to promote quality outcomes, accountability, and productivity while serving as a vital link among the RN Case Manager, Social Worker, patients, providers, payors, and community resources. Strong communication skills, sound judgment, and professionalism are critical when interacting with patients, staff, and other personnel across various age groups. The role requires adherence to clinical duties in accordance with population-specific guidelines and compliance with National Patient Safety Goals. Cross-coverage in all settings, including weekend rotations, is expected, and the position involves following identified patients for a designated period post-discharge.



Minimum Job Qualifications
  • Licensure or other certifications:
  • Educational Requirements: High School Diploma or GED.
  • Minimum Experience: Two (2) years of healthcare experience.
  • Other:


Preferred Job Qualifications
  • Preferred Licensure or other certifications: Current Georgia LPN license.
  • Preferred Educational Requirements: Licensed Practical Nurse with an active Georgia license preferred or an Associate's Degree in Health or Human Services.
  • Preferred Experience:
  • Other:


Job Specific and Unique Knowledge, Skills and Abilities
  • Excellent verbal, written, and interpersonal communication skills
  • Proficient in computer applications and data collection
  • Ability to think creatively and develop effective solutions to contemporary challenges
  • Demonstrates a strong sense of urgency while being mindful of financial stewardship opportunities


Essential Tasks and Responsibilities
  • Fosters a collaborative practice environment by utilizing a team approach to ensure service coordination and enhance continuity of patient care. Actively supports the Case Management/Social Worker role. Documents activities in patient records consistently and promptly, including progress toward goals, discharge planning, and continuum placement. Responds to all referrals on the same day received, as evidenced by documentation in the medical record.
  • Completes all tasks in a timely manner and assists in monitoring length of stay. Reviews patient medical records for appropriate documentation as requested. Proactively seeks nursing home placements once the need is identified through timely form completion, faxing, and effective communication with all parties involved. Obtains post-acute authorizations as required. Arranges appropriate discharge services for patients per physician orders, including but not limited to: Hospice, DME, Home Health Services, indigent medications from the pharmacy, transportation home, follow-up appointments, etc. Completes transfer forms for patients moving within and outside the continuum of care. Prepares DMA-6 from the medical record for patients going to SNF. Involves synthesizing information from the medical record and completing the appropriate forms. Provides requested information to nursing homes and third-party review agencies and follows up for successful patient placement. Arranges DME and/or home health services for patients per physician orders. Facilitates post-acute transportation in accordance with medical necessity and payor benefits. Serves as an advocate for the patient while assisting them in navigating the healthcare delivery system. May require face-to-face interaction at various locations. Facilitates communication among the patient, their families/caregivers, healthcare providers, and post-acute providers to enhance cooperation while planning for and meeting the healthcare needs of the patient. Facilitates post-discharge follow-up by scheduling appointments, transport, and referrals to post-acute providers.
  • Actively promotes a customer service-oriented environment to continually enhance customer satisfaction. Collaboratively works with the Case Manager or Social Worker, nursing, and physicians to achieve optimal outcomes in executing treatment/discharge plans. Communicates directly with Case Managers and Social Workers to ensure collaborative practice. Provides patient and family information as directed by the Case Manager or Social Worker regarding their financial responsibilities for inpatient and post-hospital services.
  • Works all scheduled shifts, including weekend rotations and remote coverage.
  • Actively engages as a team collaborator, fosters a positive work culture, and contributes to staff engagement. Participates in providing growth opportunities and supports redirecting negative discussions.
  • Other duties as assigned.
  • Follows identified patients for a designated period post-discharge to mitigate readmission and ensure appropriate resource utilization.


Physical Demands
  • Weight Lifted: Up to 20 lbs, Frequently 31-65% of time
  • Weight Carried: Up to 20 lbs, Frequently 31-65% of time
  • Vision: Moderate, % of time
  • Kneeling/Stooping/Bending: Frequently 31-65%
  • Standing/Walking: Frequently 31-65%
  • Pushing/Pulling: Frequently 31-65%
  • Intensity of Work: Frequently 31-65%
  • Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.


NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

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