Chronic Care Coordinator

Summary:  The Chronic Care Coordinator works under the direct supervision of the Director of Care Management and is responsible for monitoring patient health status, following up on directed care by providers and orchestrating seamless care for the patients.  The Chronic Care Coordinator interacts with patients and families via phone calls and emails to ensure comprehensive care.

Education:     High School Diploma and Certified Medical Assistant Certification or Licensed Practical Nurse Certification.

                       

Experience: 1-2 years of recent clinical experience.

Essential Job Functions:

• Performs telephonic outreach to an identified population with chronic diseases, including, but not limited to: diabetes, asthma, hyperlipidemia, heart failure, hypertension, etc. in an effort to improve the quality of their care
• Utilizes database to track patients in the Chronic Care Management (CCM) program with upcoming care plans that are due for renewal, patients who need a post-visit follow up performed, patients who are eligible for the CCM program, etc.
• Obtains patient consent and creates an annual patient driven care plan based on health goals that the patient, with the help of their primary care provider, sets for their chronic conditions indicated in their active problem list
• Provides an effective communication link between patients, medical staff, and other providers
• Performs timely follow up calls and collects health information through patient outreach
• Evaluates areas of concern, and assists patients with their health care needs, including: medical record retrieval, psychosocial support, community resources, medication assistance, etc.
• Provides ongoing education and outreach to support patient’s achievement of self-management
• Coordinate and collaborates with medical staff involved in the care of the patient; ensuring all preventative health opportunities are discussed and conducted, as appropriate
• Assist in coordination of care with primary care physician, specialists, patient, insurance companies, and other providers in the community.
• Maintains accurate and complete documentation within the EMR, Central Worklist, and other electronic databases
• Meets with office staff monthly to provide updates
• Participates in monthly CCM team meetings
• Reports information regarding quality improvement activities to Patient Care Coordinator for care gap closure

This list is not meant to be restrictive, totally inclusive, or limited in employee assignment or responsibilities.

Performance Requirements:

Knowledge, Skills and Abilities

• Strong working medical knowledge of the clinical needs and disease processes for the chronically ill population
• Knowledge of general health care practices, office work-flows, and medical terminology

• Must have good verbal and written communication skills
• Ability to work autonomously and be directly accountable for assignments
• Strong computer skills, including Microsoft office and EMR experience preferred

 

Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephone, calculators, etc.

 

Work Environment: Position is primarily in a well-lighted office environment.  This position may require limited local travel throughout the business day.

 

Mental/Physical Requirements: While performing the duties of this job, the employee is regularly required to talk or hear.  The employee is primarily sitting at a desk utilizing a computer.  

 

DISCLAIMER

The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified. Examples listed do not preclude the performance of other duties similar in nature or in level of complexity.