Care Coordinator
: Job Details :

Pathways Health Partners is an Accountable Care Organization (ACO) on the forefront of helping independent providers make the transition to Value-Based Care. Pathways operates a Medicare REACH ACO, a Medicare Advantage MSO, a Commercial MSO responsible for approximately 16,000 patients throughout North-West/Central Florida. Our service area is The Villages, down to St. Petersburg, across to Mount Dora, and areas in between. Pathways also operates a robust hospital medicine group, manages several of its affiliated medical practices, and an insurance agency.

The following information aims to provide potential candidates with a better understanding of the requirements for this role.

Job Summary

The Care Coordinator-Medical Assistant is responsible for using our software platforms to perform and document care coordination for our patients and beneficiaries between their provider visits. You'll have frequent contact with patients to provide care coordination, and support, and manage compliance with their care plan to improve health outcomes and reduce utilization/costs in your assigned population.

Role and Responsibilities

• Coordinating and assisting in developing patient-specific health plans of care
• Identifying health and social determinants of health in the assigned population
• Actively working with care team, both internal and external, to meet patient needs
• Monitoring key metrics of the assigned population to ensure goals are met
• Communicating between the care team, patients, and family/caregivers
• Educating patients about their condition(s), medication(s)
• Making patients' appointments with providers to ensure care plan adherence
• Maintaining patient confidentiality and helping to ensure quality care
• Other projects/duties as assigned potentially patient care in the clinics as needed

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