About the position The Care Coordinator is a trained professional that helps patients manage their chronic conditions by calling patients monthly. Monthly calls will include assessing current health status, educating patients about their chronic conditions, answering questions and acting as a resource between the patient and the provider, addressing any urgent patient needs, and following up on any changes in patient condition.

Responsibilities

• CCM monthly calls or verbal enrollments.
• Other services such as Health Risk Assessments, Transitional Care Management, Remote Patient Monitoring, etc.
• Communicate with patients and family members about their chronic conditions, medications, quality measures, barriers to care, and practice-specific requests.
• Communicate effectively with providers, staff, and other healthcare professionals.
• Promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s).
• Increase patients’ ability for self-management and shared decision-making, and assist patients in reaching established goals.
• Medication reconciliation.
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing healthcare costs.
• Represent CCS in a caring and professional manner to providers and other healthcare professionals.
• Comply with organizational guidelines and healthcare laws and regulations, including CMS guidelines.
• Be flexible and a team player.
• Maintain expected call volume (see Call Expectations Policy).

Requirements

• Unencumbered active CMA/RMA certificate or unencumbered active compact license LPN/RN.
• Active BLS certification
• Ability to plan and organize time effectively, work independently, and show good judgment.
• Excellent problem solving, clinical reasoning, and critical thinking skills.
• Ability to communicate effectively both verbally and in writing.
• Knowledge of CCM regulations and of CCM billing requirements.
• High proficiency in working within EHR systems.
• Operational knowledge of Google Suite, Atlas, and other required software.