What are the responsibilities and job description for the Chronic Care Coordinator position at Louisiana Family Medicine Clinic - Jonesboro?
The Chronic Care Coordinator plays a key role in supporting patients with long‑term or complex health conditions by ensuring they receive timely, coordinated, and continuous care. This position serves as the primary point of contact for patients, providers, and interdisciplinary teams, helping to improve health outcomes, reduce hospitalizations, and enhance the overall patient experience.
Key Responsibilities
Patient Coordination & Support
- Serve as the central liaison for patients enrolled in chronic care management programs.
- Conduct regular outreach (phone, or in‑person) to assess patient needs, symptoms, medication adherence, and barriers to care.
- Develop, update, and maintain individualized care plans in collaboration with providers.
- Educate patients on disease management, preventive care, and available resources.
Care Team Collaboration
- Work closely with physicians, nurses, social workers, and specialists to ensure seamless communication and follow‑through on care plans.
- Coordinate referrals, follow‑up appointments, diagnostic testing, and community services.
- Communicate changes in patient status promptly to the care team.
Documentation & Compliance
- Maintain accurate, timely documentation in the electronic health record (EHR).
- Ensure all chronic care management activities meet CMS and organizational requirements.
- Track quality metrics and support population health initiatives.
Medication & Treatment Support
- Review medication lists for accuracy and adherence.
- Assist patients with refills, prior authorizations, and pharmacy coordination.
- Identify potential medication issues and escalate to clinical staff when needed.
Patient Advocacy & Resource Navigation
- Identify social determinants of health impacting patient outcomes.
- Connect patients to community resources such as transportation, financial assistance, home health, or behavioral health services.
- Advocate for patient needs across the care continuum.
Qualifications
- Experience in care coordination, case management, population health, or a clinical support role.
- Strong understanding of chronic conditions (e.g., diabetes, hypertension, COPD, CHF).
- Excellent communication, organization, and problem‑solving skills.
- Proficiency with EHR systems and care management software.
- Ability to work independently while collaborating effectively with a multidisciplinary team.
Core Competencies
- Patient‑centered communication
- Attention to detail
- Empathy and active listening
- Critical thinking
- Time management
- Ability to navigate complex systems
- Commitment to quality and compliance
Work Environment
- Fast‑paced clinical setting
- Regular patient interaction via phone, portal, and in‑person
- Collaboration with multiple departments and providers
Benefits:
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person