The Care Coordinator acts as the lead facilitator of the multidisciplinary case management team and is a Registered Nurse (RN). The focus of the role is managing and directing high-risk, high-cost members to appropriate resources, services and programs. In order to accomplish they evaluate and plan for comprehensive coordination of care and health services to manage members across the continuum. They partner and collaborate with the integrated team and partners in order to provide seamless exchange of information between providers, members, and caregivers with the ultimate outcome to improve quality, reduce costs and enhance member experience.

• Manages both Medicare Advantage and Commercial members.


• Coordinates and manages complex medical cases and health care needs across the continuum of care.


• Conducts member assessments, identifies gaps and interventions, and coordinates ongoing care with physician and integrated team.


• Develops initial and quarterly personalized care plan with member and the primary care provider (PCP).


• Maintains continuity of longitudinal documentation appropriate for continuity of care.


• Helps the member create / coordinate a support team in their local community to help them manage their long-term health status independently.


• Tracks the top coordination tasks needed by most complex cases and when they are completed will be graduating the member to monitoring status and / or other programs.


• Lead facilitator of the multidisciplinary care coordinator team managing and directing high-risk, high-cost members to appropriate resources, services and programs.


• Care Coordinators will focus on 1% commercial and 5% Medicare targeted/prioritized complex cases, subject to further analysis.


• Creates care plan summary and communicates / discusses with the PCP and member.


• Assigned to embedded locations or geographic areas / service areas.