Care Coordinator - Ryan Health | Adair

November 20, 2020

Position Overview:

The Care Coordinator manages the smooth and consistent transfer of care as patients are discharged from the Emergency Department or Inpatient Hospital to an ambulatory outpatient setting. This position provides care coordination, health education, and health promotion services to address barriers to care and ensure that patients have access to and obtain needed medical, behavioral health and social services to optimize their health status This work is carried out in support of the mission and goals of Ryan Network.

Essential Functions:

  • Under the direction of the Director of Care Management, completes and escalates when appropriate care transition phone calls using discharge reports within 24-48 hours of discharge to prevent readmission and related complications.
  • Reminds all transition of care patients of upcoming appointments and follows up on any noshow or cancelled appointments
  • As a part of the care transition, obtains key clinical data (discharge summaries, laboratory test results, etc.) prior to the time of the patient’s initial appointment. This includes directly contacting hospital services and physicians to obtain results of care delivered at the hospital or Emergency Department
  • Coordinates PCP appointments for patients who are not engaged in primary care, identified by various data sources, including hospital care management and managed care organizations (MCO).
  • Participate in activities aimed to address social determinants of health and other concrete service needs.
  • Participates in activities related to improved care coordination and care management including both short-term and long-term follow up with patients, under the direction of the Director of Care Management
  • Develops and implements tracking methodology for patient care coordination and care management across hospital and Ryan systems
  • Screens patients for eligibility for population health and supportive services, including health homes, diabetes education, nutrition, Chronic Care Management (CCM), etc. and refers to resource when appropriate.
  • Attends all meeting and/or training sessions as required.
  • Immediately reports any problems or unusual occurrences to supervisor.

Other special projects/assignments as needed


Minimum Experience and Skills Required:

Two to four years of experience with care coordination services.

· Proven ability to provide excellent customer service.

· Excellent interpersonal and communication skills.

· Proven ability to handle multiple tasks simultaneously in a fast-paced environment.

· Good time management skills and proven ability to meet deadlines.

· Computer proficiency with electronic medical records (preferably eCW) and Microsoft programs, particularly Excel and Word.

· Comfortable dealing with a wide range of individuals, including physicians, clinical and general staff, patients, and the public.

· Ability to work flexible hours (including weekends).

Education, Licenses and/or Certifications Required:

Education, Licenses and/or Certifications Required: Bachelor’s Degree or Associate’s Degree, preferably in a medically-related or public relations field.

Preferred Qualifications:

  • Bilingual English/Spanish

Competencies Required:

Customer Service:

  • Professional, courteous and respectful attitude in dealing with patients.
  • Demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served (if applicable).
  • Commits to exceeding expectations of the patient.


  • Works well with others.
  • Contributes input to improve outcomes.
  • Asks others for opinions and feedback; provides feedback in a tactful respectful way.

Minimal Training Time:

90 actual workdays probationary period.

Working Conditions:

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit, stand, talk and hear.

The employee is occasionally required to move about the office; use hands and fingers to feel, handle, or operate office equipment.

Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work is primarily in a mental health clinic and/or general primary care setting which includes the unpredictability in behaviors of individuals and acute and chronic infectious diseases which may be contagious.


The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position. This position may be required to perform other duties. If such work becomes a permanent and regular part of the job, a new description will be prepared.

Equal Opportunity Employer

Ryan Health is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, gender identity, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.

How To Apply