Chronic Care Coordinator

Responsibilities

• 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.
• Other duties as assigned to support business operations.

Required Skills/Abilities

• 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.
• Regular, predictable onsite attendance.

Education/Experience

• 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.
• License or certification as Licensed Practical Nurse (LPN), Certified Medical Assistant (CMA), Community Health Worker (CHW) or Certified Case Manager (CCM) preferred.
• Experience working with underserved, vulnerable, or high-risk patient populations preferred.
• Experience in FQHC, primary care, managed care, or value-based care environment a plus.

• PanCare provides a comprehensive benefits package to include medical, dental and vision insurance.
• In addition, to health coverage, we offer 14 paid holidays and 3 weeks of paid vacation per year.
• Employees are also eligible to participate in our 403(b) plan with a 6% employer match and 3% base employer contribution.
• Join PanCare of Florida and be part of a dedicated team that is committed to delivering high-quality healthcare to our communities.
• We offer a supportive work environment, opportunities for professional growth, and the chance to make a real difference in the lives of our patients.
• If you're ready to take the next step in your career and contribute to our mission, we encourage you to apply today.
• Together, we can continue to improve patient outcomes and build healthier communities.
• PanCare of Florida is an Equal Opportunity Employer.
• We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by law.
• We believe that diversity and inclusion are key to our success, and we welcome applications from individuals of all backgrounds and experiences.

Monday-Friday, 8am-5pm