Chronic Care Management Coordinator
Job Description
Job Description
Benefits:
- Competitive salary
- Health insurance
- Bonus based on performance
Benefits/Perks
- Healthcare/VIsion/Dental/Life Insurance/STD/LTD
- Competitive Salary/Hourly Wages/Bonus'
We are seeking a Chronic Care Management Coordinator to join our team. In this role, the Chronic Care Coordinator performs care management for chronically ill patients with chronic diseases such as but not limited to chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Chronic Care Coordinator works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients ability for self-management and shared decision-making. The ideal candidate is compassionate, patient, and knowledgeable about healthcare practices. Responsibilities
- Conducts telephone counseling and education monthly to each CCM patient on roster/calendar.
- Complies with documentation requirements of the Chronic Care Management program and compliant with CMS guidelines by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EHR.
- Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.
- Facilitates patient access to appropriate medical and specialty providers.
- Educates patients and family/caregiver(s) about relevant community resources.
- Assist with the identification of high-risk patients (the chronically ill and those with special health care needs) and assist on the enrollment of these to the patient registry.
- Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
- Supports patient self-management of disease and behavior modification interventions.
- Provides patient health counseling, education and instruction.
- Certification as a medical assistant is preferred
- Strong problem-solving and organizational skills
- Ability to manage multiple projects or tasks and prioritize appropriately
- Ability to work in fast-paced situations and make sound decisions quickly
- Excellent interpersonal skills and high level of compassion
- Strong verbal and written communication skills
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