Care Coordinator, Embedded (Atlanta, GA - Douglasville/Southwest Atlanta)

📋 Description

• • **Join Ennoble Care: Where Compassion Meets Innovation in Mobile Healthcare**
• • Ennoble Care is a leading provider of mobile primary care, palliative care, and hospice services, dedicated to delivering exceptional healthcare directly to patients' homes. With a presence across multiple states, we are committed to providing a continuum of care for individuals with chronic conditions and limited mobility. Our innovative approach includes remote patient monitoring, behavioral health management, and chronic care management, all delivered by a trusted and familiar clinical team. We live by our motto, “To Care is an Honor,” and seek passionate individuals driven to make a tangible difference in the lives of others.
• • **The Opportunity: Embedded Care Coordinator in Atlanta, GA**
• • We are actively seeking a full-time, dedicated Care Coordinator, Embedded to join our dynamic clinical team. This crucial role involves providing on-site support within one or more of our partnered long-term care facilities, with a specific focus on the Douglasville and Southwest Atlanta areas. As an integral, in-person member of our care team, you will work collaboratively with Ennoble Care providers in a family-practice-style model. This model emphasizes building strong relationships, ensuring care continuity, and delivering truly patient-centered support within the long-term care setting.
• • **What “Embedded” Means at Ennoble Care**
• • This is not a remote or call-center position. As an Embedded Care Coordinator, you will be physically present within the long-term care facilities we serve. You will become a familiar and trusted face to residents and their families, working alongside our providers and facility staff. Your role is to foster a seamless care experience, mirroring the personalized attention of a traditional family practice but adapted for the unique environment of long-term care. This hands-on approach is central to our mission of providing high-quality, compassionate care.
• • **Key Responsibilities: Driving Patient Success and Clinical Excellence**
• • As an Embedded Care Coordinator, your responsibilities will be multifaceted, focusing on enhancing patient care, facilitating communication, and supporting clinical operations:
• • **Facility Presence & Engagement:**
• • Maintain a consistent and reliable daily presence within assigned facilities, acting as a core member of the on-site care team.
• • Proactively and regularly engage with residents to support their care plans, follow-up appointments, and care transitions.
• • Serve as a vital liaison, fostering clear communication and continuity of care between Ennoble Care providers, facility staff, residents, and their families.
• • Act as a critical communication bridge between facility staff, Ennoble Care providers, and hospice teams, ensuring seamless information flow.
• • Contribute to the development and maintenance of strong partnerships with facilities, promoting a collaborative team environment that prioritizes high-quality, patient-centered care.
• • **Clinical Communication & Care Coordination:**
• • Provide timely and accurate clinical updates to Ennoble Care providers, enabling informed and coordinated decision-making.
• • Clearly and promptly communicate patient needs, changes in condition, and urgent concerns to the clinical team.
• • Support comprehensive care coordination efforts aimed at ensuring continuity of care and preventing unnecessary hospitalizations.
• • Accurately document all patient interactions and care coordination activities, adhering to established workflows and organizational standards.
• • Follow all documentation and escalation protocols to ensure safe, efficient, and effective clinical operations.
• • **Vital Signs & Symptom Monitoring:**
• • Assist with routine and urgent vital sign collection, providing essential data for timely clinical insights and patient safety.
• • Monitor patients experiencing acute symptoms, escalating care appropriately in collaboration with the clinical team as needed (contributing to CCM billable services).
• • **Remote Patient Monitoring (RPM) & Chronic Care Management (CCM):**
• • Facilitate enrollment in Remote Patient Monitoring (RPM) programs for eligible facility-based patients, supporting data-driven, ongoing care.
• • Monitor and support patients to meet the required 16 readings per month for RPM, ensuring program effectiveness and continuity.
• • Identify and engage appropriate patients for Chronic Care Management (CCM) services, ensuring meticulous documentation and compliance with billing requirements.
• • **Telehealth Facilitation:**
• • Coordinate and support urgent telehealth visits for facility-based patients, ensuring timely access to care and maintaining clinical continuity.
• • **New Patient Referrals & Onboarding:**
• • Facilitate the clinical onboarding process for new facility-based patients, ensuring a smooth transition and prompt initiation of care.
• • Expedite the time to the first patient visit by coordinating closely with providers and care teams, promoting early engagement and seamless continuity.
• • **Staff Onboarding & Mentorship:**
• • Support the onboarding and training of new Embedded Care Coordinators, fostering confidence, consistency, and clinical excellence across the team.
• • Serve as a clinical mentor and ongoing resource for new hires, contributing to their professional growth and successful integration into the team.
• • **Our Culture: Teamwork, Respect, and Growth**
• • At Ennoble Care, we cultivate a positive and respectful work environment built on teamwork. We value each individual and encourage meaningful work while promoting a healthy work-life balance. We are committed to supporting internal advancement and long-term career growth, based on performance, organizational needs, and available opportunities. Join us and be part of a team where your contributions are recognized and your career can flourish.