Care Coordinator

JOB DESCRIPTION

Care Coordinator

Position Title: Care Coordinator

Reports To: Medical Record and Referrals Manager

FLSA Status: Non-exempt/Hourly Employee

Location: Southside

Content Last Revised: 10/15/2026

Organization Overview

The Central Florida Family Health Center, Inc. dba True Health is a private, not-for-profit federally qualified health center (FQHC) serving Central Florida since 1977. Our mission is to provide high-quality, comprehensive healthcare at a reasonable cost to everyone.

Job Summary

The Care Coordinator works with patients to ensure the highest quality of services are provided. This position provides patients and their families with educational information in conjunction with direct care providers related to treatment, procedures, medications, and continuing care requirements. They work with administration, staff, and patients to reach healthcare goals and keep the lines of communication open.

Key Responsibilities

• Plan with the patient, family/caregiver, primary care provider, support staff, payers, and community resources, to maximize healthcare responses, quality, and cost-effective outcomes.
• Facilitate communication and coordination between members of the healthcare team, involve the patient in the decision-making process to minimize fragmentation in the services.
• Educate the patient, family or caregiver, and members of the healthcare delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, care coordination, etc., so that timely and informed decisions can be made.
• Perform a variety of diverse and complex telephonic and face-to-face care coordination responsibilities and ensure that all service needs are met through monitoring of treatment plans, crisis plans and inter-agency collaboration.
• Empower the patient to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes.
• Encourage the appropriate use of healthcare services and strive to improve quality of care and maintain cost effectiveness on a case-by-case basis.
• Assist the patient in the safe transitioning of care to the next most appropriate level.
• Advocate for the patient to facilitate positive outcomes for the patient, health care team, and payers.
• Attend meetings as required to have a consistent line of communication open and assist with setting goals for quality improvement.
• Assist the referral department with referral tracking: including documentation, phone calls and sending out reminder letters of patients pending referrals.
• Scan and import documents into patients' charts as needed.
• Other duties as assigned.

Program-Specific Responsibilities

• Manage referrals received for Medication-Assisted Treatment/Substance Use Disorder program, including outreach, scheduling of appointments and follow-up needs.
• Monitor patient wait lists and assist with scheduling patients.
• Document coordination of care in the electronic health record in a timely manner that meets regulatory and accreditation standards.
• Monitor in-basket in the electronic health record and ensure timely response per policy.
• Coordinate with both internal departments and external agencies to ensure linkage to care, along with integration of behavioral health and medical care.
• Conduct assessments to identify barriers to care and service needs
• Develop and maintain individualized care coordination plans
• Assist clients with scheduling and maintaining medical, behavioral health, oral health, and supportive service appointments
• Provide linkage and referral to HIV-related medical care, treatment, prevention, and support services
• Monitor client engagement in care, appointment attendance, treatment adherence, and viral suppression outcomes
• Coordinate transportation and other supportive services necessary to facilitate access to care
• Participate in multidisciplinary case conferences and care team meetings
• Conduct outreach and re-engagement activities for clients who have fallen out of care or are at risk of disengagement from services
• Maintain timely and accurate documentation of all activities, referrals, contacts, and outcomes in the Recipient-approved electronic data management system
• Assist clients in accessing insurance, medication assistance programs and other resources necessary to support continuity of care

Essential Functions

• Problem Solving
• Customer Service
• Verbal Communication
• Written Communication
• Planning/Organizing
• Adaptability
• Initiative
• Strategic Planning

Minimum Qualifications

• Education:
• High School Diploma
• Experience:
• One (1) year minimum experience in care coordination / case management (preferred)
• Experience in Behavioral Health or HIV care coordination is a plus
• Experience with Epic EHR (preferred)
• Computer competency is required
• Community Health Worker (CHW) (preferred)
• Bilingual is a plus (English / Spanish)
• Licenses or Certifications:
• Certified or Registered Medical Assistant (preferred)

Criminal Background Clearance

True Health is a Health Center Program grantee under 42 U.S.C. 254b, a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n), and partners with agencies that require criminal background checks. True Health has established policies and procedures that may influence the overall employment process, hiring, and “just cause” for the termination of employees. An employee’s career could be shortened if there is a violation of any policies and procedures.

Prohibited criminal behavior is defined in Florida Statute (F.S.) 408.809. Any employee arrested for any offense outlined in the F.S.408.809 will be immediately suspended and remain suspended until the charges are disposed of in court. The employee will be terminated for an arrest or conviction of any violation listed above.

DRUG/ALCOHOL SCREENINGS

A post-offer drug and alcohol screen is a requirement for employment. Failure to successfully pass the drug/alcohol screen will be cause for the offer to be rescinded. Employees are subject to random drug/alcohol screenings throughout the duration of their employment with True Health. If an employee fails to pass the drug/alcohol screening, then this shall become grounds for discipline up to and including immediate termination.

WORK ENVIRONMENT

• The employee is subject to prolonged periods of sitting at a desk and working on a computer.
• The employee is subject to perform repetitive hand and wrist motions.
• The employee is frequently required to stand, walk, talk, and hear.
• The employee is occasionally required to use hands to handle or feel objects, reach with hands and arms, stoop, kneel, crouch, and move or lift up to twenty-five (25) pounds.
• The employee is required to use close vision, peripheral vision, depth perception, and adjust focus.
• A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

WORKING CONDITIONS

The employee will work as the needs of the operation require. Normal work days and hours are Monday through Thursday, 8am – 6pm and Fridays, 8am – 12pm; however, there will be times when the employee will need to come in or work on “off hours” or “off days” to meet the needs of the position.

CORE COMPETENCIES

Mission-Focused : Commits to and embraces True Health’s mission to enable access to care for uninsured and underinsured individuals.

Relationship-Oriented : Understands that people come before process and is essential in cultivating and managing relationships toward a common goal.

Collaborator : Understands the roles and contributions of all sectors of the organization and can mobilize resources (financial and human) through meaningful engagement.

Results-Driven : Dedicated to shared and measurable goals for the common good; creating, resourcing, scaling, and leveraging strategies and innovations for broad investment and community impact.

Brand Steward : Steward of True Health’s brand and understands his/her role in growing and protecting the reputation and results of the greater organization.

Visionary : Confronts the complex realities of the environment and simultaneously maintains faith in a different and better future, providing purpose, direction, and motivation.

Team-Builder : Fosters commitment, trust, and collaboration among internal and external stakeholders.

Business Acumen : Possesses a high-level of broad business and management skills and contributes to generating financial support for the organization.

Network-Oriented : Values the power of networks; strives to leverage True Health’s breadth of community presence, relationships, and strategy.

SELECTION GUIDELINES

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.