Patient Care Coordinator

Chronic Care Management Coordinator

The Chronic Care Management Coordinator works under the direction of the Manager of Social Services, providing services at the direction of the primary care provider (MD/DO/APRN). CCM Coordinator will oversee and coordinate care of up to 250 patients enrolled in WFHC CCM program during each calendar month. Services are provided outside of the face-to-face visits and focus on advanced primary care supporting the continuous relationship with a designated member of the care team to help manage and achieve quality care and positive outcomes in patients with chronic illnesses. This is a position of trust.

Good oral and written communication skills are required for this position. Information must be exchanged using tact and persuasion appropriately. The person in this position must be able to communicate with the patients, staff, and others; and contribute to a positive environment. The ability to communicate in Spanish, Creole, or both is a plus.

Key Responsibilities

1. Provides chronic care management services in accordance with CMS guidelines
   1. Ensures patient qualifies as CCM eligible having:
   • Multiple (two or more) chronic conditions expected to last at least 12 months, or until death of patient
   • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
   2. Comprehensive care plan established, implemented, revised, or monitored
2. Works closely with the front desk staff to schedule patients according to visit type and availability of the provider
3. Provides explanation and obtains patient consent for enrollment into the program
4. Establishes monthly contact with the patient and documents the required elements

Documentation and Service Requirements:

1. Structured recording of patient health information including problems, medications, and medication allergies
2. Maintains a documented comprehensive electronic care plan that is based upon a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed)
3. Manages transitions of care and other care management services
4. Coordinates sharing patient health information timely within and outside of the practice
5. Provides support for chronic diseases to achieve health goals and 24/7 patient access to care and health information
6. Provides preventative care information and schedules of appointment when required
7. Works closely with the Patient Navigator to coordinate and execute services to assist and address needs. Services inclusive of, but not limited to: Federal, State, and local programs.

Coordinates with Billing Team when billing requirements are met to ensure accurate reporting of services to payers to achieve quality and reimbursement goals

Coordinates with internal and external care team members to promote quality outcomes

Coordinate with internal and external Pharmacy Team to ensure prescriptions are updated and medications are prepared and available for patient pick-up, delivery, or mailing.

• Attend monthly meetings as scheduled.
• Communicate with providers to resolve issues related to medication management.
• Complete prior authorization for medications according to health plans.
• Initiate PAP enrollments, as requested

Complete prior authorization process for diagnostics and specialty services.

Other duties as assigned.

Education and Training

• High School Diploma required; Business Associate's degree preferred
• Proficiency in Microsoft Applications
• Proficiency in Accounting Software systems experience with Sage accounting software a plus

Experience

• Minimum of five (5) years of experience in medical assisting.
• Strong interpersonal skills with the ability to communicate effectively, both orally and in writing, with healthcare providers, patients, and staff at all organizational levels.
• Proficient in computer applications, including word processing, spreadsheets, and presentation software (e.g., Microsoft Office Suite).
• Demonstrated excellence in written and verbal communication, with attention to detail and professionalism in all forms of correspondence.

Physical Requirements

• Demonstrated ability to interact effectively and respectfully with individuals from diverse backgrounds, including but not limited to race, ethnicity, nationality, sexual orientation, gender identity and expression, socio-economic status, religion, age, English language proficiency, immigration status, and physical ability, within a multicultural work environment.
• Ability to communicate clearly and effectively in both verbal and written formats.
• Must be compliant with all required immunizations as per organizational and regulatory standards.
• Completion of a Tuberculosis (PPD) screening test required upon hire.
• Level 2 background clearance required.

WFHC reserves the right to change or modify the job description, including but not limited to Major Responsibilities, Education, Certification, and Physical Requirements.

Whole Family Health Center