Responsibilities

Job Summary: The Care Coordinator is key member of our team, who will deliver continuous patient monitoring and care coordination by assisting (virtually) chronically ill patients from a remote setting. The Care Coordinator will work closely with the patients that are enrolled in a Chronic Care Management program (CCM) and/or Remote Physiological Monitoring program (RPM). The Care Coordinator will communicate effectively and efficiently the patient’s care plan by educating via telephone each month.

Qualifications

Duties and Responsibilities:

• Conducts monthly phone calls with patients, providers, specialty practices, pharmacies, etc. to ensure assigned patients have access to what they need between regular office visits.
• Monitors and reports biometric readings such as blood pressure or blood sugar, Po2 saturation and weight. 
• Counsel enrolled patients in CCM and/or RPM to improve compliance of device utilization and care plan goals, as directed by the patient's provider.
• Coordinates with RN’s and the providers by providing input and assist in formulating personalized care plans for each patient assigned
• Documents and communicates information to and from the providers and other care resources to provide effective care to the patient.
• Accurately document for reporting and forecasting internally & externally in EMR
• Identifies social determinants of health, gaps in care, and eligibility for assistance or other referral services for assigned patients.
• Communicates positively and effectively to influence positive health outcomes.
• Manages the schedule and appropriate contact levels for servicing up to 250 dedicated patients per month.
• Provides quality based CCM/RPM program while maintaining HIPAA Regulation and safety. Adherence to ethical, legal, and accreditation/regulatory standards at all times.

Qualification and Requirements:

• 2 years healthcare experience as a CMA/CNA with current certifications with at least 1-year acute care experience.
• Call Center experience preferred.
• Patient Care coordination experience in a Chronic Care setting is preferred
• Technology experience with multiple system such as EMR/EHR, Microsoft Office, and comfortable learning new software platforms preferred
• Exceptional written and oral communication
• Outstanding interpersonal skills
• Fluent in English (speak, read, and write)
• Fluency in Spanish is high desirable (speak, read, and write)
• Strong work ethic, must be highly self-motivated, organized, and able to work independently
• Ability to handle frequent interruptions and ability to adapt to workload changes
• Ability to work or be available for full-time work (36 hours/week)