Chronic Care Coordinator-Hybrid/Remote

 

Chronic Care Coordinator – Augusta, GA Area – Hybrid/Remote    

 

Center for Primary Care:

At the Center for Primary Care our mission is to improve the health and wellbeing of the families we serve by providing compassionate and high-quality care in a joyful setting.  This mission is carried out at each of our 9 practices by our providers, healthcare professionals, and corporate support team.

For over 30 years the Center for Primary Care has been providing exceptional healthcare to our community. As our provider base expands, we are looking for a Chronic Care Coordinator who will provide excellence in the delivery of patient care and foster healthy relationships.

 

Great Place to Work:       

The Center for Primary Care is a Great Place to Work certified organization. Our certification is awarded based on direct employee feedback related to their individual work experiences.  We are dedicated to hard work and continuous improvement needed to strengthen our joyful workplace culture.    

 

General Summary:

This job opportunity is in our Augusta, GA office. The Chronic Care Coordinator (CCC – remote/hybrid) position works under the direct supervision of the Manager of Chronic Care with responsibility to the Director of Operations. The position is considered Remote (hybrid). 

Remote work is based upon the needs of the department and measurable performance data of the coordinator.  At a minimum, the coordinator will be required to attend monthly, in-person department meetings and pm training sessions, which are determined by the Director of Operations.

The Coordinator will collaborate with the Manager of Chronic Care and Director of Operations for specific Remote hours during and after the initial 30 day training period.

 

Summary

• Will be responsible for a dedicated patient panel which may include High Priority patients who have multiple chronic conditions and are at a greater risk of hospitalization.
• Will monitor the patient's health status utilizing the EMR patient portal, CCM patient portal and/or phone calls with the patient and/or their Caregiver.
• Responsible for responding to patient needs in a timely manner, based on clinical protocols related to the patient's diagnoses.
• Will communicate changes in the patient's health status to the PCP or PCP's Medical Assistant via the EMR or by phone if urgent.
• Will have defined goals for key performance indicators (KPI) for which they will be held responsible.

Principal Duties and Responsibilities

• Maintains a chronic care management dashboard for an active patient panel in the CCM software/platform, in a HIPAA compliant manner.
• Provides orientation to new CCM patients.
• Watches for patients who may be eligible for the CCM program and alerts the PCP as needed.
• Performs telephonic outreach to a dedicated active patient panel and uses the CCM platform to identify priority and urgent needs. Patients will have chronic diseases which may include, but are not limited to: diabetes, asthma, hyperlipidemia, chronic heart failure, hypertension, chronic kidney disease, etc.
• Strive to not only improve the patient's quality of care but also reduce the burden of illness (BOI), when possible.
• Obtains patient consent and creates an annual care plan based on health goals that the patient, with the help of their Primary Care Provider (PCP), sets for their chronic conditions indicated in their active problem list and clinical protocol.
• Performs timely follow up calls and collects health information through patient outreach.
• Evaluates areas of concern, and assists patients with their health care needs and access to care which may include Acute PCP appointments, chronic condition follow-up appointments, Annual Wellness Visits, medical record retrieval, information about community resources, medication assistance, etc.
• Provides ongoing education and outreach to support patient's achievement of self-management.
• Coordinates and collaborates with Providers, Medical Assistants, Quality/TCM staff members involved in the care of the patient; ensuring all preventative health opportunities, inpatient/ER follow ups are discussed, scheduled and conducted, as appropriate.
• Assists in coordination of care with the patient's PCP, specialists, insurance companies, and other health partners in the community.
• Maintains accurate and complete documentation within the EMR and other electronic databases.
• May meet with office staff monthly to provide updates.
• May participate in weekly and monthly CCM team meetings.

Benefits for you and your family:

Coverage that cares for body, mind, and spirit

Comprehensive benefits including no charge medical visits at Center for Primary Care locations

Retirement plan with employer match and profit sharing

Paid Time Off programs

Mental Health Support

 

Education and Experience Required:

High School Diploma or GED. Five years of recent Family/Internal Medicine clinical experience required.  At the discretion of the Director of Operations, other specialty experience may be considered (home health, nursing home, geriatric care, etc.).

Current Certified Medical Assistant (CMA) certification or Licensed Practical Nurse (LPN) licensure required.

Compensation:

Competitive base salary plus bonus potential.

 

Location:

Hybrid/Remote

 

Schedule:

Full-time

 

Center for Primary Care is an equal opportunity employer and complies with federal, state, and local anti-discrimination laws, regulations and ordinances.