Clinical Care Coordinator

**Clinical Care Coordinator** **Who we are:** CAMcare is made of a diverse and innovative team motivated to provide the best possible healthcare to communities in Camden and the surrounding communities. We live our values by providing primary health care to everyone, regardless of their ability to pay, at sites throughout Camden and Gloucester counties. Focused on leveling up patient care, we are incorporating technology, creative problem solving, and innovating healthcare every day. **How you can make an impact:** As a Clinical Care Coordinator (LPN) is responsible for delivering patient-centered, coordinated care in alignment with PCMH standards, HRSA FQHC requirements, and Joint Commission accreditation expectations. This role emphasizes clinical care coordination, population health management, care transitions, and quality/safety compliance within the LPN scope of practice under RN/Provider supervision. **What You Will Do:** - **Patient-Centered Care Coordination** - Conduct structured patient outreach and care coordination activities guided by risk stratification and population health registries. - Support development and implementation of individualized, patient-centered care plans under the direction of the RN/Provider. - Ensure care plans address medical, behavioral, and social determinants of health (SDOH) consistent with PCMH standards. - Facilitate closed-loop communication with patients and care teams to confirm completion of referrals, tests, and follow-ups. - **Clinical Support Within LPN Scope** - Perform clinical tasks allowed under LPN licensure (e.g., vitals, screenings, medication reconciliation, patient education reinforcement). - Identify and escalate abnormal findings, high-risk conditions, or gaps in care to RN/provider promptly. - Reinforce provider-directed education on chronic disease management, medications, and treatment adherence. - **Transitions of Care Management** - Execute post-discharge follow-up (24–72 hours) per policy, including medication reconciliation and symptom review. - Coordinate referrals and specialty care, ensuring timely scheduling and documentation of outcomes. - Reduce readmissions by ensuring clear discharge plan understanding and barrier mitigation. - **Documentation & Regulatory Compliance** - Document all encounters in the EHR accurately, timely, and in accordance with HRSA, Joint Commission, and organizational standards. - Maintain audit-ready documentation supporting: - Care coordination activities - Patient outreach attempts - Education provided - Follow-up outcomes - Use standardized templates and workflows to support quality reporting (UDS measures, HEDIS where applicable). - **Quality Improvement & Population** - Participate in quality improvement (QI) initiatives, including gap closure for preventive and chronic care metrics. - Support tracking and outreach for HRSA-required clinical quality measures (CQMs). - Utilize registries and reports to proactively manage high-risk and attributed patient panels. - **Interdisciplinary Team Collaboration** - Function as an active member of the care team (PCMH model), collaborating with providers, RNs, care managers, social workers, and behavioral health. - Participate in huddles, case conferences, and care team meetings to address complex patients. - **Patient Access & Equity (HRSA Focus)** - Assist patients in navigating care, including insurance, referrals, community resources, and enabling services. - Support access initiatives for underserved and vulnerable populations, consistent with HRSA mission. **What you Bring:** - Active Licensed Practical Nurse (LPN) license (required). - Minimum 2–3 years clinical experience in ambulatory care, primary care, or care coordination. - Demonstrated knowledge of: - PCMH principles and team-based care models - HRSA/FQHC regulatory expectations - Joint Commission standards on care coordination, safety, and documentation - Experience with EHR systems (Epic preferred) and population health…