Marshall Health·Huntington, West Virginia
Coordinates chronic care for patients by serving as an advocate and resource while integrating primary and sub-specialty management. Performs patient outreach, documents in EHR, and collaborates with providers to improve care processes and patient outcomes.
Assists physicians and other healthcare providers in identification of patients in their panel that may be eligible for services available. Coordinates care by serving as the advocate and resource for the patient. Supports primary care and sub-specialty co-management with timely communication, follow-up and integration of the patient's chronic care management. Obtains outside records from specialists or other referrals/care settings. Assists Chronic Care Manager to measure patient outcomes, review case loads, and identify any work flow issues. Works with providers to redesign care processes and improve quality. Works with patients, care-givers and providers/care team members, specialists, and community-based resources to update and execute the care plan to help patients meet goals outlined in the shared care plan. Provides outreach calls to patients enrolled in programs and documents in EHR to ensure compliance with CCM program requirements. Listens to patients and care-givers to address health issues and supports compliance with recommendations made by specialists. Facilitates patient access to care based upon the needs of the patient and family. Provides patient education related to specific chronic diseases. Works with providers to develop and implement patient education sessions. Performs other duties as assigned or requested.
Graduate of a school of nursing or medical assisting program. MA candidates must be able to obtain certification. LPN candidates must hold, or be able to obtain, a valid WV license.
Experience in a primary care setting preferred. Internal applicants must call HR at ext. 11653 to determine eligibility before applying.
Requires graduation from a nursing or medical assisting program, with certification for MAs and a valid WV license for LPNs. Experience in a primary care setting is preferred.
Market context
Chronic care coordinator roles in West Virginia are often tied to primary care settings that manage ongoing patient needs, follow-up, and care coordination. Candidates are competitive when they bring nursing or medical assisting training, the required MA certification or valid WV LPN license, and prior primary care experience. Review the AI-summarized requirements and benefits on this platform against the original posting, then confirm your credentials and prepare examples of chronic disease follow-up work.