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