Primary, Dental, and Behavioral Health

Patient Care Coordinator
Department: Medical
City/State: Longview, TX
Type: Full Time
Contact Name: Lisa Adams
Contact Email:
Date Posted: May 10, 2021

CMA experience working with the medical home concept preferred. Some experience working for a non-profit community health clinic preferred.

Previous experience working with EHR, preferably eCW

Patient Care Coordinator

Full Time

Salary DOE

Job Summary

Under the direction of the Director of Population Health, as well as oversight by the Clinic Administrator/Supervisor, the Patient Care Coordinator is part of the primary care practice team and is responsible to assist with coordinating and providing panel management services to patients within the practice who are at most risk for health deterioration or poor outcomes.

Through close collaboration with the primary care team, the Patient Care Coordinator’s role is to provide health coaching to patients to assist them in becoming informed and active participants in their care. The Care Coordinator uses a culturally-sensitive approach with all patients - in person, by telephone, or web portal. The Patient Care Coordinator also works with the Care Team to increase patient’s access to appointments, services and health care resources thereby, supporting patient’s self-care management goals.

Essential Duties/Responsibilities:

        Utilizes weekly patient lists to prioritize and execute encounters with patients who are         eligible for, or already enrolled in health coaching.

        Makes outreach calls to patients missing appointments based on preventative and chronic         disease guidelines.

        Delegates ECW telephone encounters and Web Portal messages to CMA’s, RN’s and         Providers.

        Tracks and reports the progress of assigned tasks, keeping a log of discussion topics for         team meetings and calls.

        Joins each medical visit to understand care plan, and then meets with the patient in a         private space to discuss the care plan, understand the patient’s level of engagement, and         provide health coaching according to protocol.

        Conducts weekly-to-monthly follow-up health coaching sessions by telephone according         to protocol.

        Documents patient’s progress in electronic medical record and completes all other         required documentation in timely manner.

        Maintains good communication with providers regarding treatment plans, special needs,         and progress of patients enrolled in health coaching.

        Reinforces information given to the patient and/or family with handouts to improve patient         self-management skills and communication.

        Provides as-needed teaching to patients during medical appointments.

        Acts as a point of contact for patients and families for asking questions and raising         concerns through the patient web portal and via phone.

        Participates as a member of the multi-disciplinary Care Team.

        Completes other job duties/tasks as assigned.

Teaching & Education:

  • Uses a step-by-step process when teaching skills.
  • Uses positive reinforcement and encouragement.
  • Uses a flexible approach with a diverse population.
  • Attends both mandatory in-service trainings and related meetings, providing feedback to staff on the content of educational programs attended.
  • Coaches patients to address critical issues using motivational interviews and helps patients develop achievable self-management care plan goals.


  • Completes ECW notes for all care coordination and other services provided in a timely manner.
  • Monitors and maintains confidentiality in accordance with Special Health Resources policy and legal requirements.
  • Prioritizes activities according to need, and required follow-up.
  • Provides accurate and timely reports to supervisor as required.

Interpersonal Skills/Qualifications:

1. Promotes teamwork by working in cooperation with coworkers and supervisory staff.

2. Good interpersonal skills; ability to engage with patients effectively during both in-person and telephone encounters.

3. Communicates effectively with staff and the public.

4. Able to use critical thinking to make decisions and problem solve.

5. Accepts and uses direction and supervision.

6. Ability and willingness to self-motivate, prioritize, and be agreeable to change processes to improve effectiveness.

7. Interacts in a manner which is professional, respectful, positive, helpful, and promotes trust.

8. Adapts to changing patient or organizational priorities.

9. Demonstrated ability to work and communicate with people from various ethnic, socio-economic, educational and experiential backgrounds.

10. Adheres to Infection Control protocols.

11. Acts in a manner consistent with HIPPA, the Corporate Compliance Program and Code of Conduct.

Quality Management:

1. Display knowledge of normal signs of human development and ability to assess and provide age appropriate care.

  • Contribute to the success of the organization by participating in quality improvement activities

Customer Relations:

  • Respond promptly and with caring actions to patients and employees. Acknowledge psychosocial, spiritual and cultural beliefs and honor these beliefs.
  • Maintain professional working relationships with all levels of staff, clients and the public.


  • Maintain current knowledge of policies and procedures as they relate to safe work practices.
  • Follow all safety procedures and report unsafe conditions.
  • Use appropriate body mechanics to ensure an injury free environment.
  • Be familiar with location of nearest fire extinguisher and emergency exits.
  • Follow all infection control procedures including blood-borne pathogen protocols


  • Maintain privacy of all patient, employee and volunteer information and access such information only on a need to know basis for business purposes.
  • Comply with all regulations regarding corporate integrity and security obligations. Report all behaviors and/or activities that are unethical, fraudulent, or unlawful.

High School Diploma or GED required

CMA certification required





Life Insurance

Long Term Disability