Clinical Services Coordinator

Patient Outreach, Scheduling & Care Coordination:

• Conduct proactive patient outreach to support Annual Wellness Visits, transitions of care, and preventive screenings.
• Schedule and coordinate patient appointments while addressing barriers to care and improving adherence.
• Build collaborative relationships with patients, caregivers, providers, and community partners.

Population Health & Preventive Care:

• Utilize EMR, population health registries, and AI tools to identify patients due for services and quality interventions.
• Support AWV workflows, preventive care initiatives, and value-based care programs.
• Conduct standardized screenings including health risk assessments and social determinants of health screening.

Timely Follow-Up & Transitions of Care:

• Conduct timely outreach after ED visits and hospital admissions to ensure continuity of care.
• Coordinate post-discharge appointments, medication reconciliation, and referrals as directed.
• Escalate clinical, behavioral, or social concerns to licensed clinicians appropriately.

Clinical Operations & Quality Improvement:

• Collaborate with interdisciplinary teams to improve patient engagement and reduce care gaps.
• Participate in quality improvement initiatives, workflow optimization, and implementation of new programs.
• Maintain accurate documentation within EMR and ensure compliance with organizational policies.