Patient Care Coordinator

Chronic Care Management CoordinatorThe 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:Provides chronic care management services in accordance with CMS guidelinesEnsures patient qualifies as CCM eligible having:Multiple (two or more) chronic conditions expected to last at least 12 months, or until death of patientChronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional declineComprehensive care plan established, implemented, revised, or monitoredWorks closely with the front desk staff to schedule patients according to visit type and availability of the providerProvides explanation and obtains patient consent for enrollment into the programEstablishes monthly contact with the patient and documents the required elementsDocumentation and Service Requirements:Structured recording of patient health information including problems, medications, and medication allergiesMaintains 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)Manages transitions of care and other care management servicesCoordinates sharing patient health information timely within and outside of the practiceProvides support for chronic diseases to achieve health goals and 24/7 patient access to care and health informationProvides preventative care information and schedules of appointment when requiredWorks 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 goalsCoordinates with internal and external care team members to promote quality outcomesCoordinate 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 requestedComplete prior authorization process for diagnostics and specialty services.Other duties as assigned.Education and Training:High School Diploma required; Business Associate's degree preferredProficiency in Microsoft ApplicationsProficiency in Accounting Software systems – experience with Sage accounting software a plusExperience: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