Discharge Care Coordinator

Position Status




NHC Position Type

Care Coordinator

Position Summary

The AmeriCorps member will be responsible for meeting with medical patients in our primary care program to provide them with discharge planning education and follow up care after they have met with our providers. This will include providing patients with lab work education as well as any diagnostic testing education before the patient goes for testing/procedure at Baptist Health Nassau. The member will explain the process to the patients as well as send the completed forms to Baptist Health Nassau.  The AmeriCorps member will also complete specialty care referrals for our Nassau Cares program.  Other duties will be tracking the referrals as well as following up with the patients and specialty care providers and making appointment referrals to Starting Point Behavioral Health and other preventative health services for follow up as necessary. 

The member will also provide resources for prescription assistance programs and social services that clients may need including food pantry access, Supplemental Nutrition Assistance Program (SNAP) benefits, public transportation, library access, etc.  The population mainly served at Barnabas Health Services are adults over 18 years of age that fall below the 200% federal poverty line.

Major Duties and Responsibilities

  • Meet with primary care program patients referred by the medical provider. 
  • Educate patients on discharge treatment plans.
  • Help patients complete their paperwork associated with discharge services and file appropriate forms.
  • Follow up with the patients or hospital to ensure patient obtained discharge planning services.
  • Take patient vitals as needed as follow up, refer patients that require ongoing health education on nutrition, obesity prevention, diabetes management, stress management, healthy cooking, shopping for healthy foods at the Barnabas Food Pantry, and other preventative health services to the necessary community providers of preventive health services. 
  • Make referrals to social services such as Mental Health, Rx for Healthy Living Program, Vision screenings, Women’s Hope Group, Barnabas Food Pantry, financial assistance programs, legal assistance, etc.
  • Screen patients for PAP eligibility
  • Complete, track, and follow up on specialist care referrals with the Nassau Cares Program.
  • Follow up with specialist care providers or patients by phone or in person to document that referred patients received needed services. 
  • Obtain records for services to file in patient’s chart. 
  • Document all referral coordination efforts in a tracking database for primary care program.

Characteristics of an Ideal Candidate

Member needs to be outgoing, flexible and display professionalism with a very diverse population.  Member will need to obtain DEI training.    Member should be able to serve in a fast-paced environment and be well organized and a team player.  Member should have good customer service and telephone skills. Member should have basic computer knowledge such as word and excel.  Knowledge of electronic health records will be very helpful.  

Any medical or clinical experience is a big benefit as well as being able to speak Spanish.

Knowledge Required for the Position

  • Knowledge of AmeriCorps/Health Corps member requirements
  • Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options


Member uses initiative in carrying out recurring assignments following set procedures, independently.

The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required.


The service activities are reviewed for accuracy through spot checks, through complaints from customers, and through observation of the Member at service.

Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.


Written and oral guides provide specific instructions for doing service.


Member has little or no choice about how to perform the service position. The facts or conditions of the service position are clear cut, predictable, and apply directly to the assignment.

Purpose and Impact of Service Position Assignments

The Member’s service output is necessary in order to facilitate the service of other staff.

The Member’s service position impacts on the adequacy of research conclusions. The service position product or service affects the accuracy, reliability, or acceptability of further processes or services. Service position assignments involve a variety of conventional problems, questions, or situations that conform to established criteria.

Nature of Contacts

  • Clients
  • Professional contacts with public, community groups and organizations are essential 

Purpose of Contacts

Professional contacts may also be to give or exchange information.

Special Considerations

  • Dress code: appropriate attire with closed toed shoes.
  • Transportation to and from host site necessary. Nassau Transit has service only from Yulee to Fernandina Beach ST RD 200.
  • Proof of COVID-19 vaccination

Criminal History Check Requirements Beyond NHC Standard Checks

Criminal history/background check