The MDPCP Care Coordinator works under the direct supervision of the MDPCP Program Manager and is responsible for coordinating and implementing comprehensive care management services for patients attributed to the practice under the Maryland Primary Care Program (MDPCP). The Care Coordinator works collaboratively with providers, staff, patients, and community partners to improve health outcomes, enhance patient engagement, and reduce avoidable hospital utilization.
Key Responsibilities
1. Conduct comprehensive patient assessments, including medical, behavioral, and social determinants of health needs.
2. Develop individualized care plans in collaboration with patients, families, and providers.
3. Coordinate transitions of care, including hospital discharges and emergency department follow-ups.
4. Provide education, coaching, and support to patients regarding disease management, preventive care, and self-management strategies.
5. Collaborate with interdisciplinary team members (PCPs, specialists, pharmacists, social workers, MAs) to ensure coordinated and patient-centered care.
6. Document care management activities in electronic health records (EHRs) and program platforms in compliance with MDPCP requirements.
7. Track quality metrics and support performance improvement initiatives.
8. Serve as a liaison to community resources and assist patients with referrals for social support services.
9. Participate in MDPCP-related meetings, trainings, and reporting activities as required.
Qualifications
· Bachelor’s or Master’s degree in Social Work, Nursing, or related healthcare field required.
· Active licensure in the state of Maryland (LSW, LCSW, RN, LPN).
· Minimum of 2 years’ experience in care management, case management, or population health preferred.
· Knowledge of chronic disease management, care coordination, and community resources.
· Strong communication, organizational, and problem-solving skills.
· Proficiency with electronic health records and care management platforms.
Work Setting
Hybrid position option is available upon successful completion of the 90-day probationary period. The role requires on-site care team participation and remote documentation flexibility. Collaborative, team-oriented work environment.
Benefits
· Health insurance
· Dental insurance
· Paid Time Off (PTO)
· 401(k) retirement plan (eligible after one year of employment)
Job Type: Full-time
Pay: $32.00 - $38.50 per hour
Benefits:
- 401(k) matching
- Dental insurance
- Employee discount
- Health insurance
- Paid time off
Work Location: Hybrid remote in Greenbelt, MD 20770
