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Care Coordinator

Care Coordinator

Palm Beach Accountable Care OrganizationWest Palm Beach, FL, US
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Job Description

Job Description

PBACO supports independent physicians with the tools, services, and incentives to thrive—without giving up control. We collaborate with like-minded hospital systems and

PBACO supports independent physicians with the tools, services, and incentives to thrive—without giving up control. We collaborate with like-minded hospital systems and care centers to create a seamless, integrated experience that improves outcomes and lowers costs.

About the Role

Palm Beach Accountable Care Organization (PBACO) is seeking a Care Coordinator to serve as the primary point of contact for physicians, post-acute facilities, and patients participating in our High Needs REACH program. This role combines care transition support with provider engagement and performance improvement to ensure patients experience seamless care, facilities achieve measurable outcomes, and providers receive data-driven insights.

The ideal candidate will bring strong communication skills, clinical knowledge of post-acute care and Medicare benefits, and the ability to interpret and present data to multiple audiences.

Key Responsibilities

Care Coordination

  • Monitor patient ADT (admission, discharge, transfer) alerts to identify risks and opportunities for intervention.
  • Support smooth care transitions by facilitating communication between facilities, providers, and patients.
  • Promote provider involvement in care planning and use of supportive services (therapy, ancillary care, etc.).

Provider & Facility Engagement

  • Act as the primary liaison for participating facilities and providers.
  • Conduct monthly performance review meetings and present actionable data insights.
  • Educate facility staff and physicians on REACH program requirements, PBACO policies, and care coordination best practices.
  • Deliver targeted educational visits to drive adoption of clinical initiatives.

    • Data & Reporting

  • Track and share performance metrics (readmissions, length of stay, patient satisfaction, timeliness).
  • Document all interactions with 100% accuracy and timeliness.
  • Present data insights tailored to executives, providers, facility leaders, and patients.

    • Program & Network Support

  • Collaborate with PBACO’s analytics and clinical teams to align care coordination with organizational goals.
  • Identify and escalate barriers affecting patient outcomes.
  • Support the use of technology and automation to improve care coordination.

    • Performance Goals

  • 90% of patient transitions completed with PCP follow-up.
  • 10% annual reduction in preventable readmissions.
  • 100% of assigned facilities engaged in monthly performance review meetings.
  • 95% provider satisfaction with communication and support.

    • Qualifications

  • Education : Bachelor’s degree in Healthcare, Nursing, or Administration required (Master’s preferred).
  • Experience : Minimum 2 years in SNF, HHA, care management, provider relations, or care coordination.
  • Preferred : ACO or value-based care experience; High Needs population familiarity.
  • Skills :

    • Strong Excel and data analysis skills.

  • Proficiency in Microsoft Office and care coordination platforms (e.g., CarePort, Epic, Athena).
  • Excellent written / verbal communication and relationship-building abilities.
  • Other Requirements :

    • Valid driver’s license.

  • Willingness to travel up to 2 times per month, including overnight stays.

    • Why Join PBACO?

  • Opportunity to make a direct impact on patient outcomes in a value-based care model.
  • Collaborative, mission-driven team environment.
  • Professional growth in population health, provider engagement, and healthcare transformation.
  • Apply today to help us improve patient care, reduce readmissions, and transform healthcare delivery!
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    Care Coordinator • West Palm Beach, FL, US