Care Coordinator, Embedded (Atlanta, GA - Sandy Springs)

📋 Description

• • **Join Ennoble Care: Where Compassion Meets Innovation in Patient Care**
• • Ennoble Care is at the forefront of revolutionizing healthcare by bringing high-quality primary care, palliative care, and hospice services directly to patients in their homes. With a robust presence across multiple states including New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, and Georgia, we are dedicated to providing a continuum of care for individuals managing chronic conditions and facing mobility challenges. Our comprehensive approach integrates cutting-edge remote patient monitoring, proactive behavioral health management, and dedicated chronic care management programs. We are driven by a singular mission: “To Care is an Honor,” and we seek passionate individuals who share this commitment to making a profound difference in the lives of others.
• • We are currently seeking a dynamic and dedicated **Care Coordinator, Embedded** to become an integral part of our clinical team in the **Atlanta, Georgia area, with a primary focus on the Sandy Springs vicinity**. This is a unique, full-time opportunity to work directly within one or more of our partnered long-term care facilities. You will be an in-person, essential member of our care delivery model, collaborating closely with Ennoble Care providers in a family-practice-style environment that prioritizes continuity, deep relationship-building, and truly patient-centered support.
• • At Ennoble Care, we cultivate a positive and respectful workplace culture. We believe in the power of teamwork, valuing each individual's contributions, and fostering an environment where meaningful work is balanced with a healthy work-life integration. We are committed to supporting your professional journey through internal advancement opportunities and long-term career growth, aligned with your performance and our organizational needs.
• • *Your Impact as an Embedded Care Coordinator:**
• • As an Embedded Care Coordinator, you are the vital link between our clinical team, facility staff, residents, and their families. Your consistent presence and proactive engagement within the long-term care setting are crucial for ensuring seamless care delivery and enhancing the resident experience. This role is not remote; it requires a dedicated on-site presence, allowing you to build trust and become a familiar, reliable point of contact.
• • *Key Responsibilities and Contributions:**
• • **Facility Presence & Engagement:**
• • Maintain a consistent, reliable daily presence within assigned long-term care facilities, functioning as a true embedded member of the care team.
• • Proactively and regularly engage with residents to offer support, ensure adherence to care plans, and facilitate smooth care transitions.
• • Serve as a trusted liaison, fostering clear communication and continuity of care between Ennoble Care providers, facility staff, residents, and their families.
• • Act as a critical communication bridge, ensuring seamless information flow between facility personnel, Ennoble Care clinicians, and hospice teams.
• • Contribute significantly to building strong, collaborative partnerships with facilities, promoting a unified team dynamic dedicated to 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, ensuring rapid response.
• • Support comprehensive care coordination efforts aimed at promoting continuity of care and proactively preventing unnecessary hospitalizations.
• • Meticulously document patient interactions and care coordination activities, adhering to established workflows and organizational standards.
• • Follow precise 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 clinical insights and supporting patient safety.
• • Monitor residents 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 the enrollment of eligible facility-based patients into Remote Patient Monitoring (RPM) programs, enabling data-driven, ongoing care.
• • Monitor and support patients to achieve 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 accurate documentation and compliance with billing requirements.
• • **Telehealth Facilitation:**
• • Coordinate and provide support for urgent telehealth visits for facility-based patients, ensuring timely access to care and seamless clinical continuity.
• • **New Patient Referrals:**
• • 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 visit by coordinating closely with providers and care teams, fostering early engagement and continuity.
• • **Staff Onboarding & Mentorship:**
• • Support the onboarding and training of new Embedded Care Coordinators, fostering confidence, consistency, and clinical excellence.
• • Serve as a clinical mentor and ongoing resource for new hires, promoting professional growth and effective team integration.
• • *What “Embedded” Means at Ennoble Care:**
• • This is a hands-on, in-person role. As an Embedded Care Coordinator, you will be physically present within one or more partnered long-term care facilities. You will work side-by-side with our providers and the facility's staff, building consistent relationships with residents and their families. You become a trusted, familiar face within the facility, delivering care akin to a traditional family practice, but specifically tailored for the long-term care environment. This role is fundamental to our model of providing compassionate, continuous, and high-quality care where it's needed most.