Care Coordinator
A healthcare professional — typically a registered nurse or social worker — who organizes and integrates all aspects of a patient's medical care across providers, settings, and transitions.
Care coordinators (also called case managers or care managers) serve as the organizing hub of a complex patient's healthcare system. Their activities include: assessing patient needs and goals, communicating between primary care and specialists, arranging post-acute care transitions (hospital to SNF to home), coordinating home health services, facilitating medication reconciliation (one of the highest-risk points in care transitions), connecting patients to community resources, and monitoring for care gaps.
Medicare recognizes care coordination through several billing mechanisms: Chronic Care Management (CCM, CPT 99490) for patients with 2+ chronic conditions pays approximately $62/month for 20+ minutes of non-face-to-face care coordination monthly; Transitional Care Management (TCM) pays $280–$340 per transition for the 30 days post-discharge from a hospital or SNF. These codes allow primary care practices to fund dedicated care coordinators.
Studies on care coordination programs for high-utilizing Medicare patients (top 5% of cost) consistently show 10–25% reductions in hospitalizations, 15–30% reductions in readmissions, and 10–20% reductions in total Medicare costs — driven primarily by preventing avoidable emergency department visits and managing medication adherence.
Real-World Example
After her 84-year-old father had three hospitalizations in 6 months, a family enrolled him in his primary care practice's CCM program at no cost to him; a nurse care coordinator called weekly, reconciled his 12 medications, and arranged a home safety evaluation — and he had no further hospitalizations in the following 12 months.