Chronic Care Coordinator

Job Description

Job Description

Benefits:

• 401(k)
• Competitive salary
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Benefits/Perks

• Competitive salary
• Health insurance
• 401k
• Great work-life balance
• Paid time off
• Ongoing training

Job Summary
We are seeking an organized, motivated, and dependable Chronic Care Coordinator to support our Chronic Care Management (CCM) program.

The Chronic Care Coordinator will work closely with patients, physicians, nurse practitioners, office staff, and other healthcare professionals to ensure patients with chronic medical conditions receive appropriate ongoing care and follow-up.

The position includes patient outreach, care coordination, CCM enrollment, documentation, follow-up of patient needs, and monitoring completion of monthly chronic care activities.

Key Responsibilities

• Conduct monthly outreach to patients enrolled in the Chronic Care Management program.
• Identify and assist with enrollment of eligible patients into CCM.
• Educate patients about the CCM program and obtain appropriate consent.
• Maintain and update individualized patient care plans.
• Communicate regularly with patients regarding their chronic medical conditions and healthcare needs.
• Coordinate care between patients, physicians, nurse practitioners, specialists, pharmacies, hospitals, home-health agencies, nursing facilities, and other healthcare providers.
• Assist with scheduling appointments, referrals, testing, medication-related concerns, and other care-coordination needs.
• Follow up on hospitalizations, emergency-room visits, rehabilitation stays, and transitions of care.
• Identify changes in patient condition and promptly escalate clinical concerns to the physician or advanced practice provider.
• Monitor preventive-care needs and chronic-disease care gaps.
• Maintain accurate and timely documentation in the Electronic Medical Record (EMR).
• Accurately document time spent performing qualifying CCM activities.
• Ensure assigned patients receive appropriate monthly follow-up.
• Review outstanding CCM tasks and complete them before monthly deadlines.
• Communicate with clinical and administrative staff regarding patient needs.
• Assist with tracking patient enrollment, monthly outreach, productivity, and program performance.
• Maintain patient confidentiality and comply with HIPAA and company policies.
• Participate in quality-improvement initiatives related to chronic care management.
• Perform other care-coordination and administrative duties as assigned.

Qualifications

Required:

•   A valid driver’s license, reliable personal transportation, and the ability to travel to assigned locations are required for this position.  
• Experience in healthcare, medical-office operations, patient coordination, or a related field.
• Excellent communication and interpersonal skills.
• Strong organizational and time-management skills.
• Strong computer skills and ability to work with an EMR.
• Ability to manage multiple patients and tasks simultaneously.
• Strong attention to detail and documentation.
• Ability to work independently and as part of a healthcare team.
• Understanding of patient confidentiality and HIPAA requirements.

Preferred:

• Previous Chronic Care Management (CCM) experience.
• Medical Assistant, LPN, RN, or other healthcare background.
• Experience working with Medicare patients.
• Experience working with patients with multiple chronic medical conditions.
• Familiarity with CCM documentation and billing requirements.
• Experience with care gaps, transitional care, population health, or care management.

Ideal Candidate

We are looking for someone who is:

• Compassionate and patient-focused
• Highly organized and dependable
• Comfortable communicating with patients by telephone
• Detail-oriented
• Able to follow established workflows
• Comfortable working with productivity goals and monthly deadlines
• Proactive about identifying and resolving patient needs
• Interested in chronic disease management and improving continuity of care