The Case Management Coordinator is responsible for outreaching heart failure patients who are experiencing an acute episode of care, engaging them in the Virtual Bridge Clinic, and supporting their transition across care settings. This role provides outreach, education, care coordination, and administrative support to ensure patients receive timely follow-up, medication support, and connection to community resources.

Working closely with the RN Care Manager, clinical team, and case management staff, the Case Management Coordinator helps address access to medical and social needs that impact health outcomes. This position requires strong communication skills, attention to detail, and a commitment to patient-centered care.

Key Responsibilities

Patient Identification, Outreach & Enrollment

Identify eligible heart failure patients using reports, registries, and clinical data.

Conduct outreach via phone, mail, and in-person encounters to educate patients about the Virtual Bridge Clinic and support enrollment.

Explain the importance of follow-up care, symptom monitoring, and timely access to care.

Transitional Care Support

Conduct post-discharge and post-acute Transition of Care (TOC) calls.

Schedule follow-up appointments, labs, and diagnostic tests.

Coordinate referrals to pharmacy, case management, and clinical services.

Support adherence to care plans and reinforce self-management strategies.

Addressing Social Determinants of Health

Screen patients using validated tools (e.g., SDOH assessments, PHQ-2/9, high-risk screeners).

Identify barriers such as transportation, food insecurity, housing instability, or medication access.

Provide education on community resources and facilitate referrals to appropriate support services.

Care Team Collaboration

Work with the interdisciplinary team to support care coordination activities for heart failure patients.

Communicate patient needs, barriers, and progress to RN Care Managers, pharmacists, and providers.

Assist with screenings, appointment scheduling, and patient education.

Documentation & Administrative Support

Document all interactions in the electronic medical record and care management platforms.

Maintain HIPAA standards and confidentiality of protected health information.

Prepare reports, track outreach metrics, and support program evaluation activities.

Manage high-volume inbound and outbound communication with patients, providers, and community partners.

This position is part of a two year funded grant program.

Education & Experience

High School Diploma required; Associate degree in a healthcare-related field preferred.

Minimum 2 years of experience in care management, community health work, or patient coaching.

Minimum 2 years in a client service or customer-facing environment.

Certification in Community Health Work, Medical Assistant, Pharmacy Technician, or related fieldor ability to obtain within 1 year.

Valid drivers license and reliable transportation (may be required for occasional offsite visits).

Knowledge, Skills & Abilities

Working knowledge of medical terminology, chronic disease management, and population health concepts.

Understanding of heart failure, care transitions, and social determinants of health.

Strong interviewing, listening, and coaching skills.

Ability to think critically, follow a plan of care, and escalate concerns appropriately.

Excellent verbal, written, and interpersonal communication skills.

Proficiency in Microsoft Office Suite and electronic documentation.

Ability to work independently and collaboratively in a fast-paced, evolving program.

Strong organizational skills, attention to detail, and ability to manage multiple priorities.