Care Coordination Manager – Vancleave

Join Our Team


The Care Coordination Manager will be responsible for managing/overseeing the overall function of the care coordination program. The Care Coordination Manager supports providers and the Care Coordination efforts through an integrated approach to care management, outreach and tracking, patient assistance and community outreach. As a priority, activities managed by the Care Coordination Manager will promote, maintain, and improve the health of patients and their family.

Knowledge, Skills, and Abilities

  • Knowledge about the design and function of the overall care coordination program and the interactions of each of the five pillars of care coordination within the overall team
  • Ability to provide consistent communication between the five pillars of care coordination
  • Ability to successfully manage/oversee a multidisciplinary team
  • Ability to compile and present data consistent with designated care coordination outcomes
  • Knowledge of basic care coordination terminology.
  • Knowledge of basic computer skills and proper documentation techniques within the electronic health records.
  • Ability to initiate and maintain a positive working relationship with CFHC staff and other organizations.
  • Understanding of the community/patients served
  • Understanding of behavioral health and Medicare Chronic Care Management coding/billing requirements
  • Advanced understanding of chronic care patient planning, goal setting, self-care management, etc.
  • Ability to communicate efficiently with clinic/provider teams, including verbal and listening skills.
  • The ability to travel for job duties and trainings.

Qualifications/Education Requirements

  • Completion of a degree and a licensure in clinical social work (LCSW) or Bachelors level Registered Nurse required.
  • Two or more years of experience in chronic care coordination visits and duties
  • Experience working in a multi-cultural setting.
  • Basic computer skills
  • Experience working in a federal qualified health center preferred

Core Competencies

  • Establishes a relationship with care coordination team
  • Provides ongoing managerial duties, ensuring the communication and cohesiveness of a five pillar care coordination team.
  • Compiles/analyzes set productivity and quality care outcomes consistent with chronic care coordination practices. Presents reports to the Clinical Performance Improvement Team (CPIT) and the Executive Team.
  • Leads team meetings to improve efficiencies related to chronic care coordination and to develop/enhanced care coordination workflows.
  • Assists teams in behavioral health and Medicare chronic care management billing and documentation requirements.
  • Ensures that new team members are adequately trained to perform job duties within the care coordination program.
  • May be asked to fill in care coordination duties when needed or deficiencies arise.
  • Exhibits excellent working relationships with patients, visitors and staff, effectively communicating the mission of Coastal Family Health Center (CFHC).
  • Works closely with medical provider and other clinical personnel assigned to the care team to help ensure that patients have comprehensive and coordinated care through the care coordination program.
  • Attends regular staff meetings, trainings and other meetings as requested.
  • Perform other duties as assigned.

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