Unity Health Care · 1 month ago
Patient Care Coordinator (Internal &Fam Med)
Washington, DC, US
Full-time
Onsite
Entry Level
$19.23/hr - $20.54/hr
2+ years expUnity Health Care is a healthcare organization focused on serving vulnerable populations. The Patient Care Coordinator is responsible for coordinating care for patients with complex health needs, working closely with an inter-professional team to ensure effective navigation and access to necessary services.
Health CareHospital
Responsibilities
Utilizes strength-based patient-centered motivational interviewing techniques to build rapport and help patients improve their health
Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care
Acts as a professional liaison between hospitals, primary care providers, specialists, community resources and Managed Care Organizations on behalf of patients to ensure patient-centered care coordination
Identifies and track special populations including high-risk patients and other populations due for preventive or chronic care services
Helps patients obtain the care they want and need, when they need it, which may include: assistance with financial/insurance options, solutions for transportation and translation services, and/or removal or resolution of other barriers to care
Identifies and track patients discharged from the inpatient service or the emergency department
Utilizes team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient’s care plan
Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care and disconnected from primary care
Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods
Identifies which appointments may be made for patients before leaving the clinic and strive to coordinate care before they leave (e.g., mammogram and/or specialists)
Identifies opportunities to close gaps in care
Works with inter-professional team members to identify barriers to care with the goal of finding solutions and resources to remove the barriers to care
Assists patients with navigating the healthcare system including but not limited to working with pharmacies, social service agencies, and insurance agencies as well as internal services such as the lab and other discharge processes
Participates in interdisciplinary case conferences and team meetings
Provides culturally appropriate health education
Provides cultural mediation between communities and health and human needs
Communicates patient-related needs to appropriate clinical staff including those on the patients care team as well as those providing care coordination and care management services
Acts as liaison between patient and Primary Care Medical Home in resolution of problems or referral of appropriate resource
With Support from nursing and social service staff, completes activities that helps inform the patient-centered care plan
Adheres to Unity’s HIPAA guidelines and ensures the appropriate handling of sensitive information
Performs other duties as assigned within the scope of position expectations
Responsible for the recruitment of, outreach to and the navigation and coordination of services for medically-complex and vulnerable patients
Serves as a member of an inter-professional 'overlay' team composed of a Registered Nurse (RN) and a Site Program Coordinator. The team collectively manages care for difficult-to-reach patients and those that have higher levels of acuity, either because of health status or due to frequent utilization of the hospital system
Supports the development and implementation of care coordination processes alongside care management team including but not limited to Registered Nurses, Social Service staff and My Health GPS program staff
Manages a panel of complex, high-risk patients that are not well connected to care through outreach, scheduling of appointments, sharing in appointment visits and follow up of specialty visits
Provides care coordination and navigation of services for patients following ER visits and hospitalization
Performs home visits to recruit and maintain relationships with patients in need of coordinates care; complete community and home-based follow-up visits as needed
Perform community-based outreach activities and working with referring providers in a clinical setting
Builds positive rapport with staff on care teams
Mentors site-based Care Coordinators to improve quality of services delivered to patients
Qualification
Required
High school diploma or GED
Two (2) years of experience providing care coordination service
Experience working as a part of an inter-professional team
Knowledge of medical terminology, ICD10 and procedural codes
Familiarity with community health, discharge planning, chronic disease management
Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must
Ability to work collaboratively in a team and manage multiple priorities, utilizes effective time management skills, and exercise sound professional judgment
Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences
Proven ability to work collaboratively and productively with clinicians, administrators, patients, and other individuals from various backgrounds and skill sets
Must have the ability to analyze data
Demonstrated proficiency with business software (i.e., Microsoft Office Suite, EMR)
Requires the ability to travel to multiple office locations
Preferred
College coursework in business or health-related field is preferred
Experience in a hospital and/or community/outpatient setting is preferred
Company
Unity Health Care
Unity Health Care provides a full range of health and human services to meet the needs of communities.
Founded in 1985Washington, District of Columbia, USA
1001-5000 employees
H1B Sponsorship
Unity Health Care has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (4)
2024 (1)
2023 (2)
2022 (4)
2021 (6)
2020 (2)
Funding
Current Stage
Late StageTotal Funding
$3.3MKey Investors
Health Resources and Services AdministrationThe J. Willard and Alice S. Marriott Foundation
2024-11-22Grant· $1M
2023-04-18Grant· $2.3M
Leadership Team
Janelle Goetcheus
Founder
Jesse Barber
Founder
Recent News
District of Columbia Health
2025-06-11
Seattle TechFlash
2025-04-29
Seattle TechFlash
2025-04-28
Company data provided by crunchbase