As a Clinical Care Coordinator at Vituity, you will support patients through the continuum of care, coordinating services across emergency, inpatient, and post-acute settings. You'll conduct assessments, develop and update care plans, and collaborate closely with physicians, nurses, social workers, and community partners to reduce readmissions and improve outcomes. In Vituity's caring, team-driven culture, you'll help patients navigate complex medical and psychosocial needs while advancing clinical excellence, innovation, and compassionate, patient-centered care. Responsibilities Perform comprehensive patient assessments to identify medical, social, and psychosocial needs Develop, implement, and update individualized care plans in collaboration with the care team Coordinate services and transitions between emergency, inpatient, and post-acute or community settings Educate patients and families on diagnoses, treatment plans, and available resources Communicate regularly with physicians, nurses, social workers, and external partners to align care Monitor patient progress and adjust care plans to reduce readmissions and improve outcomes Document all care coordination activities accurately in the EHRConnect patients with community resources, support services, and follow-up care Participate in quality improvement initiatives to enhance care delivery and patient experience Advocate for patient needs while supporting Vituity's standards for clinical excellence and compassion Required Skills Care coordination Patient assessment Discharge planning Electronic Health Records (EHR) Interdisciplinary team collaboration Utilization management Care plan development Healthcare documentation Patient and family education Community resource navigation