Chronic Care Coordinator

Chronic Care Coordinator

Job Summary

We are seeking a dedicated and detail-oriented Chronic Care specialist to enhance patient outcomes through proactive care coordination. The ideal candidate will possess a strong background in healthcare delivery, medical coding, and case management, with a focus on managing chronic conditions. This role involves coordinating care plans, ensuring compliance with healthcare regulations, and supporting patients in managing their health effectively.

Key Responsibilities

• Coordinate and monitor ongoing care for patients with chronic conditions, ensuring adherence to personalized care plans.
• Utilize CPT coding, ICD-9, and ICD-10 coding systems accurately for documentation and billing purposes.
• Collaborate with healthcare providers, social workers, and behavioral health specialists to develop comprehensive discharge planning and follow-up strategies.
• Manage medical records meticulously, ensuring HIPAA compliance and confidentiality at all times.
• Conduct intake assessments to identify patient needs and facilitate appropriate case management interventions.
• Support discharge planning processes by coordinating post-acute care services and patient education.
• Maintain thorough documentation of patient interactions, medical terminology, and treatment progress within electronic health records.
• Engage in patient service activities that promote understanding of medical conditions and foster ongoing engagement in care.

Essential Functions

• Complete individualized patient-centered care plans and provide management services using CCM software.
• Maintain frequent patient contact to coordinate care, provide support, and ensure program compliance to improve outcomes.
• Communicate emergent needs or life-threatening episodes to Psychiatric Clinicians.
• Accurately document all verbal and written client communications in a timely manner.
• Manage a caseload of up to 500 members.
• Coordinate with schedulers to set and verify all required patient appointments.
• Manage referrals and review member medications as necessary.
• Qualify members for end-of-month billing and add them to the billing system.
• Create and update care plans and review member charts as needed.

Qualifications

Proven experience working within hospital or acute care settings is highly preferred.

Strong knowledge of medical coding practices including CPT, ICD-9, ICD-10, and medical terminology.

Familiarity with social work principles, behavioral health integration, and pediatrics is advantageous.

Experience in discharge planning, case management, and intake procedures is essential.

Excellent organizational skills with attention to detail in managing medical records and documentation.

Ability to communicate effectively with multidisciplinary teams while maintaining HIPAA compliance.

Knowledge of hospital workflows, patient service protocols, and medical records management is desirable.

A background in medical coding or healthcare administration will be considered an asset. Join our team to make a meaningful difference in the lives of patients managing complex health conditions through compassionate care coordination and clinical excellence!

Preferred Skills

• Strong oral, written, and phone communication skills.
• Ability to work independently with excellent organization and time management.
• Knowledge of clinical practices, diagnostic procedures, and treatment protocols.
• Strong clinical judgment and critical thinking skills.
• Ability to build trusting relationships with patients and partner practices in a fast-paced environment.
• Results-oriented with a focus on quality and daily productivity.
• Proven problem-solving, consultative, and customer service skills