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Complex Care Coordinator

Cadillac, MI


Posted on August 15, 2018

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About Complex Care Coordinator


The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:

  • Promote timely access to appropriate care

  • Increase utilization of preventative care

  • Reduce emergency room utilization and hospital readmissions

  • Increase comprehension through culturally and linguistically appropriate education

  • Partner with Emergency Department staff for safe discharge to community or next level of care

  • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)

  • Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals

  • Increase patients’ ability for self-management and shared decision-making

  • Provide medication reconciliation

  • Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs

  • Perform utilization management for those patients being admitted to the hospital

Success in this position will lead to improved health for the patient and reduced health care costs for the managed population of patients.


Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources

  • Work with patients to plan and monitor care:

  • Assess patient’s unmet health and social needs

  • Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)

  • Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed

  • Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time

  • Facilitate patient access to appropriate medical and specialty providers

  • Educate patient and family/caregiver(s) about relevant community resources

  • Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed

  • Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals

Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR)

  • Attend all Care Coordinator training courses/webinars and meetings

  • Provide feedback for the improvement of the Care Coordination Program

Provides brief and limited counseling services and crisis interventions to patients and families in need of special support, adjustment to illness, adjustment to discharge plan, support at death or other social emotional needs.

Provides immediate intervention and connection to long term community resources in cases including child abuse/neglect, domestic violence, elderly abuse, institutional abuse, and sexual assault

Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations, including hand off to complex care manager.


  1. Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.

  2. Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.

  3. Demonstrates ability to work autonomously and be directly accountable for duties.

  4. Demonstrates ability to influence and negotiate individual and group decision-making.

  5. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

  6. Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving and decision-making, priority setting, work delegation and work organization.

  7. Core values consistent with a patient- and family-centered approach to care

  8. Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal

  9. Demonstrates a positive attitude and respectful, professional customer service

  10. Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations

  11. Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns

  12. Proactively continues to educate self on providing quality care and improving professional skills


  13. Support the mission, vision, and values of the organization.

  14. Treat others and their ideas with respect and dignity.

  15. Set a good example for others.

  16. Be an active coach for everyone in the organization.

  17. Maintain the highest standards of honesty, integrity, and communication.

  18. Insist on excellence and be accountable to one another.

  19. Build group cohesiveness and pride through teamwork.

  20. Demonstrate confidence in Munson Health Care and its workforce in all areas of the community.

  21. Value and promote creativity and the change process.

  22. Be a good communicator and listener; be available and visible.

  23. Develop yourself to your highest potential.

  24. Active participation in Quality Initiatives

    Education / Experience

Minimum Required education- Baccalaureate prepared Social worker or Nurse licensed in state of Michigan.

  • 3-5 years’ experience in clinical or community resource settings; Care coordination and/or case management experience is desirable

  • Evidence of essential leadership, communication, education, and counseling skills

  • Proficiency in communication technologies (email, cell phone, etc.)

  • Highly organized with ability to keep accurate notes and records

  • Experience with health IT systems and reports is desirable

  • Local knowledge about and connections to community health care and social welfare resources is desirable

  • Ability to speak a relevant second language is desirable

Job at a Glance

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