Community Based Care Coordinator

Western Maryland Health System, Inc – Cumberland, MD


Job Summary: The Community Care Coordinator partners closely with community PCPs and specialists and is responsible for patient coordination of care across the care continuum for a designated population. Care coordination includes planning, facilitation, education and encouragement of self-management of patients. This role interfaces with others within the home setting, acute facilities, post-acute nursing facilities and home care with linkage and communication to PCP office/provider. S/he will have a thorough understanding of care continuum coordination services, eligibility requirements, and resources available in the community. This role actively collaboratively partners with providers, hospital personnel, external & internal intake personnel, and patient & family in the assessment, planning, implementation and evaluation of the care needs for the patient. This position actively advocates, plans for and identifies immediate, short term and long term care needs for the patient with engagement and a focus toward patient self-management and attainment of patient s goals.

Responsible for providing coordination of care, clinical care support, physician instruction reinforcement, medication management, post-acute hospital and provider visit follow-up interventions and promoting disease identified self-care management for chronically-ill, or high-risk patient populations with a focus toward better clinical outcomes and reducing unnecessary emergency department visits and unscheduled hospital admissions.

Education: Associates Degree in Nursing is Required. Bachelor s Degree in Nursing is preferred.

Licensure: State of Maryland Registered Nurse License is required.

Certifications: Certification in care management nursing or health coaching is preferred. BLS-Basic Life Support Certification is required, but will provide training if necessary.

Experience: A minimum of five years experience in acute care and/or home care setting required. Experience in emergency/urgent care setting, intensive care unit, home care or community-based care management programs strongly preferred.

Skills: Requires strong telephonic and communication skills. Knowledgeable with EClinical Works software, Microsoft applications and highly effective computer user.

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