Chronic Care Coordinator - Marshall Internal Medicine

Marshall Health•Huntington, WV

About The Position

This role assists physicians and other healthcare providers in identifying patients eligible for services and coordinates their care by acting as a patient advocate and resource. The position supports primary care and sub-specialty co-management through timely communication, follow-up, and integration of chronic care management. Responsibilities include obtaining outside records, assisting with outcome measurement and workflow analysis, and working with providers to redesign care processes for quality improvement. The coordinator collaborates with patients, caregivers, care teams, specialists, and community resources to update and execute care plans, ensuring patients meet their goals. They conduct outreach calls to enrolled patients, document in the EHR for compliance, and address patient health issues and specialist recommendations. Facilitating patient access to care and providing education on chronic diseases are key functions. The role also involves working with providers to develop and implement patient education sessions and performing other assigned duties.

Requirements

Graduate of a school of nursing or medical assisting program.
MA candidates must be able to obtain certification.
LPN candidates must hold, or be able to obtain, a valid WV license.
Experience in a primary care setting preferred.

Responsibilities

Assists physicians and other healthcare providers in identification of patients in their panel that may be eligible for services available.
Coordinates care by serving as the advocate and resource for the patient.
Supports primary care and sub-specialty co-management with timely communication, follow-up and integration of the patient's chronic care management.
Obtains outside records from specialists or other referrals/care settings.
Assists Chronic Care Manager to measure patient outcomes, review case loads, and identify any work flow issues.
Works with providers to redesign care processes and improve quality.
Works with patients, care-givers and providers/care team members, specialists, and community-based resources to update and execute the care plan to help patients meet goals outlined in the shared care plan.
Provides outreach calls to patients enrolled in programs and documents in EHR to ensure compliance with CCM program requirements.
Listens to patients and care-givers to address health issues and supports compliance with recommendations made by specialists.
Facilitates patient access to care based upon the needs of the patient and family.
Provides patient education related to specific chronic diseases.
Works with providers to develop and implement patient education sessions.
Performs other duties as assigned or requested.