Clinical Coordinator

Position Overview

Essential Duties and Responsibilities

• Coordinate patient identification, referrals, eligibility review, enrollment, and baseline information collection. Ensure that the treating provider confirms clinical eligibility and that required consent and program documentation are completed.
• Assess care coordination needs within professional scope, including barriers related to transportation, connectivity, health literacy, medication access, and social support. Arrange appropriate referrals and track their completion.
• Coordinate appointments, monitoring reviews, laboratory follow-up, nutrition counseling, lifestyle coaching, and other services identified in the care plan. Communicate outstanding needs and changes in patient status to the responsible clinician.
• Support transitions between hospital, outpatient, home, and community settings. Reinforce clinician-provided instructions and confirm follow-up arrangements with patients, caregivers, and receiving teams.

• Coordinate patient onboarding to approved monitoring devices and platforms, including education, setup, initial transmission checks, and access to technical assistance. Track engagement and address missed transmissions or interrupted participation.
• Track assigned monitoring information and alerts using approved workflows. Route abnormal findings, concerning trends, and patient-reported symptoms to the appropriate clinician within established response timeframes. Clinical interpretation and assessment are performed by appropriately licensed staff.
• Track clinical alerts and follow-up tasks through documented resolution. Escalate urgent findings, unanswered alerts, and safety concerns through established clinical and emergency procedures.
• Support standardized care pathways for diabetes, hypertension, and related conditions. Coordinate reassessment and follow-up after clinician-directed changes to treatment or monitoring plans.

• Provide culturally responsive education using approved materials and teach-back methods. Help patients and caregivers understand program expectations, device use, symptom reporting, and chronic disease self-management.
• Collect patient-reported medication information and identify access or adherence barriers using approved procedures. Route discrepancies, possible adverse effects, and treatment questions to licensed clinicians; support follow-up and documentation of medication reconciliation.
• Provide nursing assessment or pharmacist-led medication review and counseling only when supported by the individual’s license, competence, and institutional authorization. Implement medication changes only under authorized orders or approved collaborative arrangements.

• Serve as a clinical coordination contact for participating sites and interdisciplinary teams. Facilitate case reviews, clarify handoffs, and communicate operational barriers to clinical leadership and the program manager.
• Support staff orientation and training on care pathways, documentation, monitoring workflows, and escalation procedures. Help maintain current protocols and practical workflow guidance with clinical subject-matter experts.
• Work with health coaches, community health workers, and community partners to maintain patient engagement and access to services while preserving clear responsibilities for clinical care.

• Document patient contacts, assessments performed, monitoring reviews, referrals, interventions, and follow-up accurately and promptly in the electronic health record and approved program systems.
• Work with program managers and data analysts to track enrollment, engagement, retention, response times, referral completion, data completeness, and patient experience. Support reporting and quality reviews with accurate clinical documentation.
• Identify care gaps and workflow problems, participate in case and safety reviews, and help implement and evaluate corrective actions. Escalate incidents and confidentiality concerns through institutional channels.
• Follow applicable professional standards, institutional privacy and security requirements, and approved project procedures. For research activities, support protocol adherence, required training, and documentation under the direction of the investigator and research team.

• Degree in nursing or pharmacy, or a bachelor’s degree or higher in biology, biomedical sciences, health sciences, physiology, nutrition, or a related science discipline from an appropriately accredited institution. Nursing associate degrees, BSN, Bachelor of Science in Pharmacy, and PharmD qualifications are accepted.

• Professional licensure is not required for science graduates performing coordination duties. Nursing or pharmacist duties require the corresponding active license, authorization to practice in West Virginia, and applicable institutional credentials; these duties are assigned only to appropriately licensed staff.
• At least one year of relevant experience in healthcare, clinical research, patient or participant coordination, chronic disease programs, or a related health sciences setting.
• Knowledge of chronic disease care and patient education, with the ability to recognize concerns requiring escalation and coordinate timely follow-up within professional scope.
• Strong communication, organizational, and interpersonal skills; ability to manage multiple patient needs and collaborate with clinical, research, administrative, and community teams.
• Proficiency with electronic health records and routine office software, with the ability to learn remote monitoring and telehealth systems and maintain accurate, confidential records.
• Ability to travel to participating clinical sites and community locations as required by assigned projects.

• Advanced degree in a relevant science or health discipline, BSN, or PharmD.

• Experience with diabetes, hypertension, obesity, cardiometabolic disease, or patients with multiple chronic conditions.
• Experience in outpatient or primary care, rural or underserved communities, transitional care, population health, or interdisciplinary chronic disease programs.
• Experience with RPM, connected devices, telehealth, clinical research coordination, quality improvement, or grant-funded healthcare programs.