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Care Coordinator - MDPCP
Clinical Operations
Waldorf, MD
Full Time

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Title/Position: Maryland Primary Care Program Care Coordinator

Department or Business Unit: Population Health, Mid Atlantic

Overview of the Role:

The Maryland Primary Care Program (MDPCP) Care Coordinator will work closely with Primary Care providers in the state of Maryland to identify, screen, track, monitor, and coordinate the care of patients with multiple chronic conditions to develop and deliver Comprehensive Primary Care to patients. Our Care Coordinators seek to develop, implement, and deliver extensive care coordination within our medical group and affiliated partners in a patient centered manner. They interact and collaborate with interdisciplinary care teams, population health teams, networked facility partners, physicians, and others involved in meeting the patient’s needs

Primary Job Duties: 

  • Collaborate with assigned local teams to meet Maryland Primary Care Program performance metrics
  • Own the execution and performance toward defined performance metrics
  • Collaborate effectively with integrated care team to support care coordination for patients
  • Review patient non-compliance reports and conduct telephonic and/or in person outreach to ensure timely disease specific and wellness visits
  • Provide Transitional Care Management including, but not limited to, post in-patient and/or emergency department discharge follow up
  • Provide education and assistance as it relates to lifestyle coaching, dietary improvements and plans
  • Provide education and assistance in accessing the necessary care outside of the Primary Care Office
  • Collaborate with providers to review high-risk patients, develop a plan of care, and administer Care Plan to patients
  • As needed, meet patients in the office or community for face-to-face visits
  • Provide education and assistance with patient self-management goals
  • Identify and coordinate referrals to community resources, home care, and disease management programs within Privia Preferred Network
  • Operate independently within defined practice(s) and patient population to achieve agreed upon goals
  • Attendance and participation in regular care team meetings to discuss patient care
  • Perform other duties as assigned 

Minimum Qualifications:

  • 2-5 years of population health or care coordination experience
  • Health Coach clinical certification and/or experience
  • Strong computer and EHR skills and expertise 
  • Preferred experience with Medicare aged patients in a value-based program 
  • Preferred experience educating and engaging patients 
  • Experience working in an outpatient medical office 
  • Ability to travel to and from care centers to meet with patients and providers
  • Must comply with all HIPAA rules and regulations

Interpersonal Skills & Attributes:


  • Great communicator - creates clarity and adjusts style to expertise of audience
  • Comfortable in a fast-paced environment and with ambiguity 
  • Highly collaborative and effective across an organization and region amongst multiple stakeholders
  • Performance Driven – knows the team’s goals and how to prioritize personal and daily activities to meet those metrics
  • Team focused: understands the need to work as a group to achieve goals, support team members, and listen to other points of view
  • Demonstrates sound judgment 
  • Ability to function independently efficiently and meet defined goals
  • Must be detail-oriented and possess critical thinking skills
  • Possess a focused work ethic and a high level of professionalisms

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Technical Requirements for Remote Work:

In order to successfully work remotely, supporting our patients and providers, we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests like This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.

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