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Start the day excited to make a difference...end the day knowing you did. Come join our team.
The Community Clinical Care Coordinator (Community C3) is responsible for managing patient transitions from inpatient to outpatient care, ensuring continuity, safety, and efficient use of health system resources. Serving as a consistent point of contact for patients and families during the high-risk post-discharge period, the role supports patients and families by addressing medical, psychosocial, and logistical needs. The Community C3 collaborates closely with providers, ancillary teams, and community agencies to reduce care fragmentation, prevent avoidable readmissions, and optimize follow-up care. The role contributes to improved patient outcomes and system-wide efficiency.
Essential Functions and Responsibilities:
- Serves as a consistent point of contact for patients, families, providers, and community resources post-discharge.
- Coordinates follow-up care across inpatient and outpatient teams and ensures timely initiation of post-acute services such as home health, DME, medications, and appointments.
- Facilitates access to long-term support services and resolves barriers to care, including service delays, affordability and insurance issues, and gaps in social determinants of health (e.g., transportation, housing, food insecurity, caregiver support).
- Manages post-discharge inquiries by serving as the central point of contact for patients, families, and providers, reducing callbacks to inpatient teams and improving care continuity.
- Coordinates with pharmacies, insurers, and providers to expedite medication access and prior authorizations.
- Documents interventions in Epic and contributes to system reporting on readmissions, follow-up volume, and care coordination outcomes.
- Educates patients and families on post-discharge care plans and available community resources to support recovery and prevent readmissions.
- Guides hospital and community staff on outpatient care coordination, available resources, and patient navigation processes.
- Performs other duties as assigned.
Qualifications:
- Associate's degree in nursing required.
- Valid RN license in the state of Virginia or a reciprocal compact state required.
- Minimum of three (3) years recent acute care nursing or case management experience.
- Bachelor of Science in Nursing preferred.
- Experience with Epic or equivalent electronic medical record system preferred.
- Prior case management/discharge planning experience preferred.
- Certification in case management (ACM, CCM) or other relevant specialty preferred.
As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.
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Mary Washington Healthcare
Oct 24, 2025