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Care Coordination Specialist

2 months 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 role encompasses a variety of support functions for the Case Management team. The individual will assist the RN Case Manager and Social Worker in discharge planning, placement within the care continuum, liaising with insurance providers, and data collection. Collaboration with physicians and other healthcare professionals is essential to support patient care monitoring, coordination, and facilitation. The position aims to promote quality outcomes, accountability among team members, and effective communication between the RN Case Manager, Social Worker, patients, providers, payors, and community resources. Strong communication skills, sound judgment, and professionalism are crucial when interacting with patients and staff across all age groups, from neonates to geriatrics. Clinical responsibilities must align with population-specific guidelines and adhere to established safety protocols. Cross-coverage in various settings, including weekend rotations, is expected. The individual will follow designated patients for a specified period post-discharge.



Minimum Job Qualifications
  • Licensure or other certifications:
  • Educational Requirements: High School Diploma or GED.
  • Minimum Experience: Two (2) years of experience in healthcare.
  • 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 challenges
  • Demonstrates a strong sense of urgency while being mindful of financial stewardship


Essential Tasks and Responsibilities
  • Fosters a collaborative practice environment through a team-oriented approach to ensure service coordination and enhance patient care continuity. Documents all activities in the patient record promptly, including progress towards goals, discharge planning, and placement within the care continuum. Responds to all referrals on the same day they are received, as evidenced by documentation.
  • Completes all tasks efficiently and assists in monitoring patient length of stay. Reviews medical records for necessary documentation as requested. Proactively seeks nursing home placements once identified needs arise through timely form completion and effective communication with all parties involved. Obtains post-acute authorizations as needed. Arranges appropriate discharge services per physician orders, including but not limited to: Hospice, DME, Home Health Services, and transportation home. Completes transfer forms for patients moving within and outside the care continuum. Prepares DMA-6 forms from medical records for patients transitioning to skilled nursing facilities. Provides requested information to nursing homes and third-party review agencies, ensuring successful patient placements. Coordinates DME and/or home health services as per physician orders. Arranges post-acute transportation based on medical necessity and payor benefits. Serves as an advocate for patients, assisting them in navigating the healthcare system. May require face-to-face interactions across various campuses or patient locations. Facilitates communication among patients, families/caregivers, healthcare providers, and post-acute providers to enhance cooperation in planning and meeting patient healthcare needs. Ensures post-discharge follow-up by scheduling appointments, transport, and referrals to post-acute providers.
  • Actively promotes a customer service-oriented environment to enhance patient satisfaction. Collaborates with Case Managers, Social Workers, nursing staff, and physicians to achieve optimal outcomes in executing treatment and discharge plans. Communicates directly with Case Managers and Social Workers to ensure collaborative practices. Provides patients and families with information regarding their financial responsibilities for inpatient and post-hospital services as directed by the Case Manager or Social Worker.
  • Works all scheduled shifts, including weekend rotations and remote coverage.
  • Actively engages as a team collaborator, fostering a positive work culture and contributing to staff engagement. Participates in opportunities for professional growth and supports constructive dialogue.
  • Other duties as assigned.
  • Monitors identified patients for a period post-discharge to reduce readmission rates 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.