Community Care Team Coordinator en Harrington Family Health Center

Position Summary

The Community Care Team Coordinator serves as the primary access point for all referrals to the Community Care Team. This position combines community paramedicine training with care coordination responsibilities to ensure timely, seamless, and patient-centered follow-up for individuals referred from within the FQHC and triage and management of requests for follow-up services for requests that originate outside of the FQHC.
 
The Coordinator works collaboratively with the Community Care Team to identify patients who may benefit from additional support through hospital discharge summaries, in-house referrals,  post-visit follow-up, and requests for external parties. This role emphasizes proactive care coordination, ensuring that patients receive the right level of medical, behavioral, and social support at the right time. By maintaining strong communication between departments and conducting targeted outreach, the Coordinator promotes continuity of care, reduces preventable readmissions, and supports HRSA quality measures.

This position is grant-funded through the Community Paramedicine: Serving Rural Mainers Project, supported by Community Care Partners of Maine. The project’s goals are to expand the number of organizations implementing community paramedicine programs across Maine, increase overall CP referrals, reduce costly emergency transports and avoidable emergency department visits, and improve patient satisfaction and health outcomes at participating sites. Funding for this role is secured through November 2026, with continuation contingent upon renewal or additional grant awards.

Essential Duties and Responsibilities

Community Care Coordination

·         Identify patients in need of care coordination through hospital discharge summaries, internal referral alerts, emergency department notifications, requests from external third parties, and office visit follow-up reports.

·         Serve as a consistent point of contact for patients transitioning between hospital, specialty, and primary care settings.

·         Conduct outreach calls or visits to assess ongoing medical, behavioral, and social support needs.

·         Work collaboratively with providers and CCT staff to create or update individualized care plans.

·         Monitor patient progress and engagement in care plans, escalating to the RN Care Manager or provider when clinical follow-up is required.

·         Assist with scheduling follow-up appointments and coordinating resources to reduce barriers to care (transportation, housing, food insecurity, insurance, etc.).

Community Paramedicine Functions

·         Conduct home or community visits as appropriate for transitional care or chronic disease follow-up as outlined by Maine EMS education standards.

·         Perform basic clinical assessments, vital signs, wound checks, medication reviews, and patient education under approved protocols.

·         Identify and communicate patient needs requiring RN or provider involvement.

·         Support telehealth connections and transportation coordination when barriers are identified.

·         Collaborate closely with CHWs and Patient Navigators to address social and environmental factors affecting health.

Program and Quality Support

·         Participate in daily or weekly care team huddles to review new referrals and care plans.

·         Document all encounters and outreach accurately within the EHR and MEFIRS

·         Assist in maintaining workflows, policies, and procedures for the Community Care Team.

·         Track and report metrics related to referral closure rates, hospital transitions, and patient engagement.

·         Promote communication across clinical, behavioral, and administrative departments to ensure continuity of care.

Qualifications

Required

·         Active Maine EMT License.

·         Minimum of (2) years of EMT experience

·         Commitment to complete a certified Community Paramedicine program as scheduled.

·         Proficient in electronic health record documentation and data tracking.

·         Excellent communication, organizational, and problem-solving skills.

·         Valid driver’s license.

Preferred

·         Prior experience in an FQHC, hospital, or care management setting.

·         Knowledge of HRSA enabling services and quality improvement measures.

·         Familiarity with social service systems and community resource navigation.

Working Conditions

·         Combination of office, clinical, and field environments.  Occasional lifting (up to 25 pounds) of medical or educational equipment.

·         Frequent driving to patient homes and community sites within the service area.

Benefits

·         Wage: $20/hour

·         Health, dental, and vision insurance.

·         Paid time off

·         Continuing education support

·         Opportunity to help shape an innovative mobile integrated care program.

Location

Harrington is located in Downeast Maine, a wild and beautiful coastal area sporting outdoor recreation opportunities for fantastic land and water activities. Less than two hours from Bangor, Maine’s third largest city and Acadia National Park, the country’s 6^th most-visited national park, you will find a lifestyle rich with beauty and experience. The community’s population relies on traditional lobster fishing, blueberry harvesting, and wreath production. The scarcity of nearby affordable medical and dental options makes our Community Health Center a truly mission driven place to work.

Equal Opportunity Statement

Harrington Family Health Center is an Equal Opportunity Employer and values diversity at all levels of the organization. We encourage applications from individuals of all backgrounds and experiences who share our commitment to equitable, accessible, and compassionate healthcare for all.