Chronic care management coordinator

Responsibilities

• Patient Engagement & Outreach
• Identify eligible patients, introduce CCM services, and enroll in CCM program by obtaining consent.
• Conduct and maintain monthly outreach to CCM-enrolled patients.
• Perform follow-up calls related to chronic condition management.
• Identify and escalate barriers to care (appointments, medications, social needs).
• Care Coordination
• Coordinate care across providers, specialists and community resources.
• Track referrals, lab results, and follow-up needs.
• Support transitions of care activities by following up with patients discharged within 48-business hours of notification and assisting with scheduling post-discharge care.
• Focus on closing Gaps in Care (GIC).
• Participate in monthly Health Impact Team (HIT) and Multidisciplinary Team (MDT) meetings.
• Manage patient status and monitor progress towards health goals.
• Provide support for patient self-management activities and assess barriers to treatment or adherence.
• Documentation & Time Tracking
• Document CCM activities in the electronic health record (EHR).
• Track accurate time spent on qualifying CCM services.
• Ensure documentation supports billing requirements.
• Care Plan Support
• Assist with development of Care Plan by providing patient reported information.
• Reinforce Care Plan goals with patients.
• Review Care Plan and identify when updates are needed and notify providers.
• CCM Workflow & Program Support
• Review CCM patient rosters regularly.
• Identify and support patients nearing the 20-minute billing threshold.
• Support implementation of CCM workflows at the site level.
• Collaborate with Care Teams and Site Champions.
• Assist with CCM training and meetings as needed.
• Quality & Compliance
• Ensure CCM services align with regulatory requirements.
• Participate in audits and quality improvement activities.
• Maintain HIPAA compliance.
• May be assigned other tasks and duties reasonably related to job responsibilities.

• Competencies
• Possesses strong assessment, critical thinking, and problem-solving skills within the scope of role.
• Manages multiple patients and prioritizes tasks effectively.
• Executes follow-up timely and has strong organizational skills.
• Demonstrates strong interpersonal skills including effective oral, written, and telephonic communication with patients and Care Teams.
• Explains Care Plans and reinforces instructions clearly.
• Manages time efficiently and complete CCM activities consistently and timely.
• Demonstrates initiative in identifying and completing patient outreach.
• Collaborates with colleagues consistently and is able to work as part of a team.
• Presents as goal-oriented and accountable.
• Documents activities and tracks time accurately.
• Follows structured workflows and compliance requirements.
• Identifies barriers to care and escalates appropriately.
• Works effectively with providers, nurses and Care Team members as well as specialists, hospitals and community resources/agencies.
• Supports and demonstrates team-based care models within the Health Centers and within the Department.
• Demonstrates competency in various software applications.
• Possesses strong data analytic skills and interest in tying data to clinical outcomes.
• Adjusts to workflow changes and program needs.
• Maintains openness to feedback and continuous improvement.
• Actively participates in departmental and organizational committees and meetings as applicable.

Qualifications

• High School Diploma or equivalent experience required.
• Bachelor's degree in health-related field, Certified Medical Assistant (CMA), Certified Professional in Healthcare Quality (CPHQ) or similar certifications preferred.
• Two or more years experience in healthcare or case management preferred.
• Experience working with patients with chronic conditions preferred.
• Working knowledge of computer software and electronic health records.
• Basic computer skills (Microsoft Office, data entry).
• Understanding of chronic disease management concepts preferred.
• Familiarity with care coordination or population health workflows preferred.
• Bilingual Spanish or Creole required.

SALARY: Commensurate with experience

More information

This is a non-exempt position.

HHLI provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, gender, marital status, sexual preference and orientation, or non-disqualifying physical or mental handicap/disability in each aspect of the human resources function. Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The HHLI shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.