Key Responsibilities and Required Skills for Care Coordinator

🎯 Role Definition

The Care Coordinator is a clinical and administrative professional responsible for managing individualized care plans, facilitating care transitions, and acting as the central point of contact for patients, families, and interdisciplinary teams. This role focuses on improving patient outcomes, reducing avoidable readmissions, coordinating community and clinical resources, ensuring documentation in the electronic medical record (EMR), and driving measurable improvements in population health metrics. The ideal candidate demonstrates strong clinical judgment, patient advocacy, excellent communication skills, knowledge of payor requirements (Medicare/Medicaid), and proven experience with care coordination or case management workflows.

📈 Career Progression

Typical Career Path

Entry Point From:

Medical Assistant, Community Health Worker, or Patient Service Representative transitioning into care coordination
Registered Nurse (RN), Licensed Practical Nurse (LPN) or Social Worker (BSW) moving into case management
Discharge Planner, Patient Navigator, or Behavioral Health Technician with relevant experience

Advancement To:

Senior Care Coordinator / Lead Care Coordinator
Nurse Case Manager or Licensed Clinical Case Manager
Population Health Manager or Care Coordination Supervisor
Director of Care Management, Clinical Operations Manager, or Program Director

Lateral Moves:

Utilization Review Nurse / Specialist
Discharge Planner or Transitions of Care Specialist
Community Health Program Coordinator or Patient Engagement Manager

Core Responsibilities

Primary Functions

Conduct comprehensive biopsychosocial and clinical assessments for assigned patients, synthesizing medical history, current diagnoses, functional status, social determinants of health, and caregiver support to create individualized, evidence-based care plans documented in the EMR.
Develop, implement, and continuously update patient-centered care plans that include short- and long-term goals, required services, medication reconciliation, follow-up appointments, and measurable outcome targets aligned with payer and organizational quality metrics.
Coordinate and schedule multidisciplinary care team meetings with physicians, nurses, social workers, therapists, home health agencies, and community-based organizations to ensure continuity of care and shared understanding of the care plan.
Facilitate safe and efficient transitions of care across settings (hospital to home, home to skilled nursing facility, outpatient to specialty care), including discharge planning, patient education, post-discharge follow-up calls, and reconciliation of medications and home care services.
Serve as the primary patient and family advocate by addressing barriers to care (transportation, housing, food insecurity, language), connecting patients to community resources, and escalating clinical or social concerns to the appropriate team members.
Perform utilization review and authorization activities, preparing and submitting prior authorization documentation, communicating with payers, and ensuring services are medically necessary and compliant with payer policy.
Monitor and manage a defined caseload of high-risk patients using risk stratification tools and population health registries, conducting proactive outreach to reduce avoidable ED visits and hospital readmissions.
Provide evidence-based patient education and self-management coaching for chronic disease (diabetes, COPD, heart failure, behavioral health conditions), using teach-back methods to confirm understanding and adherence.
Conduct home assessments or virtual visits when indicated to evaluate home safety, caregiver capabilities, and need for durable medical equipment, home health, or community supports.
Maintain timely, accurate, and compliant clinical documentation in the organization’s EMR (e.g., Epic, Cerner) including care plans, progress notes, discharge summaries, authorizations, and outcome data for auditing and quality reporting.
Track and report care coordination metrics (readmission rates, HEDIS measures, no-show rates, medication adherence, patient satisfaction scores) and use data to identify opportunities for process improvement.
Coordinate referrals to specialty care, behavioral health services, substance use treatment, and social services, ensuring timely appointments and closure of referral loops through follow-up verification.
Conduct timely outreach to patients after hospitalization or emergency department visits to assess status, reinforce discharge instructions, and expedite appointments or prescriptions as needed.
Liaise with payors, case management teams, and community agencies to resolve coverage questions, appeals, and complex care authorization issues impacting patient access to care.
Support care transitions programs and hospital-at-home or telehealth initiatives by triaging needs, arranging equipment or in-home services, and providing continuous telephonic or virtual monitoring.
Identify and escalate high-acuity clinical concerns to physicians or advanced practice providers immediately, coordinating urgent care referrals and emergency interventions when safety risks are identified.
Train, mentor, and provide guidance to junior care coordination staff and allied health colleagues on workflows, documentation standards, and patient engagement techniques to maintain program fidelity and service excellence.
Participate in quality improvement projects, root cause analyses, and committee work to redesign care pathways, reduce care fragmentation, and improve clinical and financial outcomes.
Maintain up-to-date knowledge of federal and state regulations (Medicare, Medicaid), organizational policies, and evidence-based guidelines to ensure compliance and optimize care delivery.
Facilitate advanced care planning discussions as appropriate, document patient wishes, support palliative care or hospice referrals, and coordinate end-of-life care within the clinical team.
Manage complex medication reconciliation across settings, communicating changes to prescribing providers, and identifying potential adverse drug interactions or adherence barriers.
Conduct regular follow-up and monitoring for patients enrolled in transitional care or disease management programs, adjusting interventions based on progress and patient feedback.
Use motivational interviewing and solution-focused counseling to support behavior change, medication adherence, and engagement with preventive services and chronic disease self-management.
Establish and maintain effective relationships with community-based providers and social service agencies to expand resource networks and streamline referral pathways for patients.

Secondary Functions

Participate in population health and care management program development, including protocols, care pathways, and resource guides to standardize care coordination practices.
Contribute to the development and maintenance of patient education materials, care transition packets, and culturally appropriate communication tools.
Assist with collection and validation of data for internal audits, quality reporting, and value-based care contracts (e.g., ACO, bundled payments).
Support outreach campaigns and patient engagement workflows to improve preventive care uptake (immunizations, screenings) and chronic disease monitoring.
Provide input to product teams or IT on EMR configuration needs, templates, and workflows to enhance documentation efficiency and care coordination reporting.
Provide cross-coverage for peers during staffing shortages, ensuring continuity of care for high-risk patients and timely response to urgent coordination needs.

Required Skills & Competencies

Hard Skills (Technical)

Care coordination and case management for complex adult and/or pediatric patient populations.
Proficient use of electronic medical records (EMR/EHR) systems such as Epic, Cerner, or Meditech for documentation, task management, and care plan updates.
Prior authorization and utilization management processes, including knowledge of Medicare and Medicaid coverage rules and appeals workflows.
Discharge planning and transitions-of-care best practices, including medication reconciliation and home health coordination.
Chronic disease management (e.g., diabetes, CHF, COPD) and evidence-based interventions to reduce readmissions.
Strong clinical assessment skills, including triage, basic vital sign interpretation, and recognition of clinical deterioration.
Experience with patient risk stratification tools, population health registries, and quality measure reporting (HEDIS, readmission metrics).
Case documentation and compliance with HIPAA, state regulations, and organizational policies.
Familiarity with community resources, social service systems, and referral platforms (e.g., Unite Us or local resource directories).
Telephonic and telehealth care management workflows, remote patient monitoring basics, and virtual visit coordination.
Basic data literacy: extracting, interpreting, and using patient-level and program-level data to drive interventions.

Soft Skills

Exceptional verbal and written communication for patient education, care team collaboration, and documentation.
Strong organizational and time-management skills to manage a high-volume caseload and competing priorities.
Empathy and cultural competence to build trust with diverse patient populations and caregivers.
Critical thinking and problem-solving to develop pragmatic care plans and address barriers to care.
Collaboration and teamwork across clinical and community-based stakeholders.
Patient advocacy mindset with the ability to escalate and negotiate effectively on behalf of patients.
Resilience and adaptability to work in fast-paced, changeable healthcare environments.
Motivational interviewing and coaching skills to support behavior change and self-management.
Attention to detail for accurate documentation, medication reconciliation, and compliance activities.
Conflict resolution and de-escalation techniques for crisis situations or complex family dynamics.

Education & Experience

Educational Background

Minimum Education:

Associate degree in Nursing (ADN), Social Work (ASW), or related allied health field; or equivalent clinical experience with certification.

Preferred Education:

Bachelor’s degree (BSN, BSW, BA/BS in Public Health, Healthcare Administration, or related field).
Registered Nurse (RN) license, Licensed Clinical Social Worker (LCSW), or Certified Case Manager (CCM) preferred for clinical roles.

Relevant Fields of Study:

Nursing (ADN/BSN)
Social Work (BSW/MSW)
Public Health / Health Promotion
Healthcare Administration / Health Services Management
Behavioral Health or Mental Health Counseling

Experience Requirements

Typical Experience Range: 1–5 years of direct patient care or care coordination/case management experience (varies by level)

Preferred:

2+ years of care coordination, case management, discharge planning, or population health experience.
Prior experience with EMR systems (Epic/Cerner), utilization management, and working within value-based care or ACO environments.
Certifications such as CCM, RN-BC, or CNM and training in motivational interviewing or chronic disease management are advantageous.