Chronic Care Coordinator

We are growing! We are expanding our Chronic Care Management team and seeking two new Chronic Care Coordinators. At PanCare of Florida, our mission is to bring quality healthcare to underserved communities. We believe that compassionate, dedicated healthcare professionals are essential to fulfilling this promise. Are you a dedicated and detail-oriented Chronic Care Coordinator looking to make a meaningful impact on patient care? In this role, you will be at the forefront of ensuring the safe and effective use of medications, working closely with healthcare professionals and patients to optimize treatment outcomes. If you have a passion for patient safety, a keen eye for detail, and thrive in a fast-paced environment, we invite you to apply and become a vital part of our mission to provide exceptional healthcare services. The Chronic Care Coordinator supports patient-centered, team-based care by coordinating services across the continuum of care, addressing barriers to care, and connecting patients with medical, behavioral, and community resources. They work closely with providers, care manager, and interdisciplinary team members to improve patient outcomes, reduce avoidable utilization, and support quality initiatives including HEDIS, UDS, value-based care, Chronic Care Management (CCM), Advanced Primary Care Management (APCM)and Remote Patient Monitoring (RPM). The Care Coordinator is responsible for enrolling, engaging, and managing patients across the practices Advanced Primary Care Management (APCM), Chronic Care Management (CCM), and Remote Patient Monitoring (RPM) programs. This role serves as the primary point of contact for patients between office visits, ensuring care plans are followed, chronic conditions are monitored, device data is reviewed, and all clinical and administrative activity is documented in compliance with CMS billing requirements. Responsibilities Conduct patient outreach and engagement activities for assigned patient populations. Assistpatients in navigating healthcare services and overcoming barriers to care. Coordinate care transitions following hospitalizations, emergency department visits, and specialty care encounters. Facilitate communication among primary care providers, specialists, behavioral health providers, and community partners. Monitor patient adherence to treatment plans and follow-up recommendations. Assistpatients with appointment scheduling and transportation arrangements as needed. Participate indevelopmentand implementation of individualized care plans. Assistwith risk stratification and identification of patients requiring care management services. Support enrollment and ongoing management of patientsparticipatingin CCM,APCMand RPMprograms. Monitor patients with chronic conditions and provide education on disease self-management. Document care coordination activities in the electronic health record and care management platforms. Collaborate with referral staff toaddress barriers preventing patients from receiving recommended services. Screen patients for social needs,includingfood insecurity, housinginstability,transportationneeds, financial barriers,andutility assistance needs. Connect patients to community resources and social service agencies. Advocate for patients experiencing barriers that negativelyimpacthealth outcomes. Support initiatives designed to improve HEDIS, UDS, and value-based performance measures. Participate in outreach campaigns for preventive screenings and chronic disease management. Assistwith annual wellness visits andcaregap closure activities. Prepare reports and track performance metrics as assigned. Document all patient interactions accurately andtimelyin the electronic health record. Maintain patient confidentialityin accordance withHIPAA and organizational policies. Completerequired reports, registries, and care management documentation within established timelines. Monitor assigned work queues and ensuretimelyresolution of patient needs. Demonstrate commitment to organizational compliance and quality standards by following established policies and procedures,maintainingregulatory requirements, participating in quality improvement efforts, and reporting concerns throughappropriate channels. Other duties as assigned to support business operations. Required Skills/Abilities Knowledge of Medicare, Medicaid, and community resources. Familiarity with HEDIS, UDS, CCM, APCM, and value-based care initiatives. Strong organizational and time-management skills. Excellent verbal and written communication skills. Ability to work independently and collaboratively within interdisciplinary teams. Proficiencywith electronic health records and Microsoft Office applications. Ability to manage multiple priorities in a fast-paced environment. Regular, predictable onsite attendance. Education/Experience High school diploma or equivalent required. Associate's degree in healthcare administration, social work, public health, nursing, or related field preferred. Minimum of two years of experience inhealthcare,care coordination,casemanagement,populationhealth,communityhealth, ormedical office operationspreferred. License or certification as Licensed Practical Nurse (LPN), Certified Medical Assistant (CMA), Community Health Worker (CHW)or Certified Case Manager (CCM)preferred. Experience working with underserved, vulnerable, or high-risk patient populations preferred. Experience in FQHC, primary care, managed care, or value-based care environmenta plus. PanCare provides a comprehensive benefits package to include medical, dental and vision insurance. In addition, to health coverage, we offer 14 paid holidays and 3 weeks of paid vacation per year. Employees are also eligible to participate in our 403(b) plan with a 6% employer match and 3% base employer contribution. Join PanCare of Florida and be part of a dedicated team that is committed to delivering high-quality healthcare to our communities. We offer a supportive work environment, opportunities for professional growth, and the chance to make a real difference in the lives of our patients. If you're ready to take the next step in your career and contribute to our mission, we encourage you to apply today. Together, we can continue to improve patient outcomes and build healthier communities. PanCareof Florida is an Equal Opportunity Employer. We do not discriminateon the basis ofrace, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by law. We believe that diversity and inclusion are key to our success, and we welcome applications from individuals of all backgrounds and experiences. #J-18808-Ljbffr PanCare Health