The primary responsibility of this position is to work with multidisciplinary healthcare teams in a primary care setting with the focus on coaching and coordination of care for designated high-risk patients while working along side primary care providers, care teams, and office staff in a PCMH, focusing on identifying the needs of complex patients while assisting the practice to develop a process for managing its patient population. The PCMH Care Coordinator uses effective communication strategies among family, the medical home, schools, specialists and community professionals and community connections to help improve, measure, monitor and sustain quality outcomes (clinical, functional, satisfaction and cost containment).