Care Coordinator Specialist

The Care Coordination Specialist provides individualized patient navigation, referral management, scheduling coordination, and administrative support for the Hudson Valley Rural Cancer Prevention and Follow-Up Network. The position works closely with patients, healthcare providers, laboratories, specialty practices, community organizations, transportation resources, and program staff to ensure timely completion of colorectal and prostate cancer screening, diagnostic testing, specialty referrals, and follow-up care.

This role combines patient navigation responsibilities with scheduling and referral coordination functions to ensure patients successfully move through the cancer screening continuum. The position proactively identifies and resolves barriers to care, coordinates appointments and referrals, maintains accurate records, supports grant-defined closed-loop referral tracking, and serves as a key operational resource for patients and participating healthcare providers.

The position supports implementation of grant-funded cancer screening initiatives and does not independently provide clinical services or make clinical decisions.

RESPONSIBILITIES

Patient Navigation and Engagement

• Contact assigned patients using approved outreach and navigation protocols.
• Educate patients regarding program processes and reinforce provider-approved instructions.
• Assist patients with completion of screening tests, preparation requirements, appointments, and diagnostic follow-up activities.
• Support patients throughout colorectal and prostate cancer screening pathways.
• Conduct outreach to patients who have incomplete, overdue, or pending screening and follow-up activities.
• Coordinate distribution and completion of FIT kits and other approved screening resources.
• Maintain ongoing communication with patients to encourage completion of recommended care.
• Document patient interactions and navigation activities in approved tracking systems.

Referral Management and Care Coordination

• Validate referrals received from participating practices and healthcare providers.
• Determine eligibility for screening services, diagnostic colonoscopy, PSA testing, and specialty referrals using approved protocols.
• Coordinate appointments with primary care, gastroenterology, urology, laboratories, imaging providers, and specialty services.
• Track referral status from initial referral through documented completion or closure.
• Monitor abnormal screening results and ensure patients are connected to appropriate next steps.
• Coordinate communication between patients, providers, specialists, laboratories, and program partners.
• Support the program's closed-loop referral process by documenting completed services, recommended follow-up, or patient refusal.
• Utilize approved scripts, workflows, and escalation pathways for all patient communications.
• Escalate abnormal results, urgent concerns, unresolved barriers, clinical questions, or overdue follow-up items to licensed clinical personnel.

Barrier Assessment and Resolution

• Assess and document transportation, language, communication, financial, scheduling, technology, and other barriers affecting access to care.
• Connect patients with approved transportation, interpretation, community resources, financial assistance programs, and other support services.
• Collaborate with community partners to address social determinants of health affecting screening completion.
• Develop individualized strategies to help patients overcome barriers and remain engaged in care.
• Monitor ongoing needs and adjust support plans as appropriate.

Scheduling and Administrative Coordination

• Coordinate patient, provider, partner, and program-related scheduling activities.
• Track appointment readiness, required documentation, pending actions, and follow-up requirements.
• Monitor screening and referral workflows to ensure timely completion of needed steps.
• Coordinate meeting logistics, attendance records, materials, action items, and follow-up communications as assigned.
• Maintain calendars, scheduling records, task lists, and workflow trackers.
• Support operational implementation activities associated with screening and navigation programs.

Documentation and Program Support

• Maintain accurate and timely documentation of patient contacts, outreach attempts, appointments, referrals, barriers, outcomes, and escalation activities.
• Maintain referral databases, action logs, contact lists, and program tracking tools.
• Support preparation and distribution of forms, correspondence, educational materials, and program documentation.
• Track and report status updates, overdue activities, missing information, and outstanding actions.
• Assist with data collection, reporting, and quality improvement activities.
• Support grant reporting requirements through accurate documentation and record maintenance.

Team Collaboration and Partner Communication

• Serve as a liaison among patients, providers, navigation staff, laboratories, specialists, healthcare organizations, and community partners.
• Coordinate information exchange between navigation, clinical, operational, outreach, data, and administrative teams.
• Participate in multidisciplinary case reviews, team meetings, training sessions, and quality improvement initiatives.
• Support workflow refinement and implementation of best practices.
• Foster positive relationships with participating healthcare organizations and community resources

​​​​​EXPERIENCE

• Experience supporting patients, coordinating care, managing referrals, healthcare scheduling, customer service, community health, care coordination, or patient navigation activities.
• Ability to work collaboratively across clinical, operational, administrative, data, and community-based teams.
• Strong organizational, interpersonal, communication, documentation, and follow-through skills.
• Proficiency with Microsoft Office applications and the ability to learn electronic health records and tracking systems.
• Ability to maintain confidentiality and comply with HIPAA, privacy, and security requirements
• Experience as a Patient Navigator, Community Health Worker, Medical Assistant, Care Coordinator, Referral Specialist, Oncology Navigator, or similar role, preferred.
• Experience with healthcare scheduling, referral management, population health, or cancer screening programs, preferred.
• Knowledge of colorectal cancer screening and prostate cancer screening processes, preferred.
• Experience working with rural, underserved, or vulnerable populations, preferred.
• Knowledge of transportation resources, community support services, and barriers to preventive care, preferred.
• Bilingual or multilingual, preferred.
• Experience supporting grant-funded healthcare initiatives.

EDUCATION

• High school diploma or equivalent required.
• Associate degree, bachelor's degree, or equivalent healthcare-related experience preferred.

LICENSES/CERTIFICATIONS

• N/A

OTHER

• Patient-centered communication and motivational engagement techniques.
• Patient navigation and care coordination principles.
• Referral management and closed-loop tracking processes.
• Barrier assessment and resource coordination.
• Healthcare scheduling and appointment management.
• Customer service and relationship management skills.
• Accurate documentation and recordkeeping practices.
• Ability to work within established protocols and escalation procedures.
• Strong problem-solving and organizational abilities.
• Ability to manage multiple priorities and maintain attention to detail.
• Proficiency with electronic tracking systems and standard office software.
• Commitment to improving access to preventive healthcare services in rural and underserved communities.
• Sound judgment regarding issues requiring escalation to licensed clinical personnel or leadership

SPECIAL REQUIREMENTS

• N/A