What You’ll Be Doing
The Care Coordinator plays a key role in supporting patients with complex medical needs. Working under the supervision of the Manager, Chronic Care Management, you will work directly with patients, providers, and care teams to ensure coordinated, patient-centered care within a skilled nursing facility setting. This role emphasizes patient engagement, care planning, and ongoing follow-up to prevent unnecessary hospitalizations and promote better health outcomes. In this role you will be required to spend 8-2pm in the skilled nursing facility in midtown Savannah and can work remotely for the rest of the day.
Key Responsibilities
- Deliver chronic care management services to patients with complex or high-risk conditions.
- Conduct assessments of medical, educational, and psychosocial needs using standardized tools (e.g., depression, functional, and risk assessments).
- Collaborate with providers, specialists, and families to support development and updates of individualized care plans.
- Help identify and prioritize patients for medical services each day, including prepping any charts to enable efficient and effective provider visits.
- Provide patient and family education, focusing on self-management and capacity for self-care.
- Coordinate care transitions, including timely post-hospital follow-up, medication reconciliation, and education on discharge instructions.
- Document all care management activities accurately and in a timely manner.
- Participate in process improvement activities and quality initiatives.
Skills & Abilities
- Strong clinical knowledge of chronic disease management.
- Excellent communication skills (verbal, written, and listening).
- Ability to engage with patients and families in a supportive, empathetic, and culturally competent manner.
- Strong organizational skills and attention to detail.
- Ability to work independently while collaborating with providers and team members.
- Problem-solving skills with a focus on patient-centered outcomes.
Qualifications
- Must be a Licensed Practical Nurse (LPN) or Certified Medical Assistant (MA).
- Minimum 1–2 years of experience in chronic care management, primary care, ambulatory care, skilled nursing, or hospital settings
- Experience with care management documentation and EHR systems preferred.
- Associate’s degree or higher in a clinical or health-related field preferred.
- Ability to spend most mornings on site, but flexibility beyond that
Benefits Package
- Medical, Vision, and Dental Insurance via Health Reimbursement Account
- 401(k) Plan after first year of employment
- Paid Vacation, Paid Sick Time, and 10 Paid Holidays
- Set schedule, no weekends
- Family-friendly work environment
Why Fortis Care
At Fortis Care, we believe every patient deserves attentive, high-quality care delivered where they are. Our physician-led team partners with nursing facilities to provide expert, consistent, and compassionate medical services right at the bedside.
We take a holistic approach to health, combining medical expertise with chronic care coordinators who ensure patients’ needs are met across the continuum of care. From reducing avoidable hospitalizations to empowering patients and families with tools for self-management, our mission is to improve outcomes while treating every patient with dignity and respect.
As part of Fortis Care, you’ll join a collaborative, mission-driven team that values independence, ownership, and doing the right thing for patients and partners. We invest in our people, celebrate hard work, and provide opportunities to grow alongside a company that is redefining post-acute care.