Chronic Care Coordinator

Role Overview

• Conduct patient outreach and engagement activities for assigned patient populations
• Assist patients 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
• Assist patients with appointment scheduling and transportation arrangements as needed
• Participate in development and implementation of individualized care plans
• Assist with risk stratification and identification of patients requiring care management services
• Support enrollment and ongoing management of patients participating in CCM, APCM and RPM programs
• 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 to address barriers preventing patients from receiving recommended services
• Screen patients for social needs, including food insecurity, housing instability, transportation needs, financial barriers, and utility assistance needs
• Connect patients to community resources and social service agencies
• Advocate for patients experiencing barriers that negatively impact health outcomes
• Support initiatives designed to improve HEDIS, UDS, and value-based performance measures
• Participate in outreach campaigns for preventive screenings and chronic disease management
• Assist with annual wellness visits and care gap closure activities
• Prepare reports and track performance metrics as assigned
• Document all patient interactions accurately and timely in the electronic health record
• Maintain patient confidentiality in accordance with HIPAA and organizational policies
• Complete required reports, registries, and care management documentation within established timelines
• Monitor assigned work queues and ensure timely resolution of patient needs
• Demonstrate commitment to organizational compliance and quality standards by following established policies and procedures, maintaining regulatory requirements, participating in quality improvement efforts, and reporting concerns through appropriate channels

Requirements

• 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 in healthcare, care coordination, case management, population health, community health, or medical office operations preferred
• 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
• Proficiency with electronic health records and Microsoft Office applications
• Ability to manage multiple priorities in a fast-paced environment

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• 14 paid holidays
• 3 weeks of paid vacation per year
• 403(b) plan with a 6% employer match
• 3% base employer contribution