CHRONIC CARE MANAGEMENT COORDINATOR

Harmony Health Care Long Island•Hempstead, NY

2d•$50,000 - $55,000•Onsite

About The Position

The Chronic Care Management (CCM) Coordinator will join the Care Coordination Department with the goal of supporting Medicare patients who are diagnosed with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges, and are at risk for Emergency Department (ED) or inpatient admission or worsening of conditions. The CCM Coordinator would develop partnerships and trust with patients, facilitate communication between patients and Care Team members, coordinate non-face-to-face care services and address Social Determinants of Health (SDOH) to reduce hospitalizations and improve daily functioning. This role ensures that CCM services are consistently provided, appropriately documented, and aligned with regulatory and organizational standards.

Requirements

High School Diploma or equivalent experience required.
Working knowledge of computer software and electronic health records.
Basic computer skills (Microsoft Office, data entry).
Bilingual Spanish or Creole required.

Nice To Haves

Bachelor's degree in health-related field, Certified Medical Assistant (CMA), Certified Professional in Healthcare Quality (CPHQ) or similar certifications preferred.
Two or more years experience in healthcare or case management preferred.
Experience working with patients with chronic conditions preferred.
Understanding of chronic disease management concepts preferred.
Familiarity with care coordination or population health workflows preferred.

Responsibilities

Identify eligible patients, introduce CCM services, and enroll in CCM program by obtaining consent.
Conduct and maintain monthly outreach to CCM-enrolled patients.
Perform follow-up calls related to chronic condition management.
Identify and escalate barriers to care (appointments, medications, social needs).
Coordinate care across providers, specialists and community resources.
Track referrals, lab results, and follow-up needs.
Support transitions of care activities by following up with patients discharged within 48-business hours of notification and assisting with scheduling post-discharge care.
Focus on closing Gaps in Care (GIC).
Participate in monthly Health Impact Team (HIT) and Multidisciplinary Team (MDT) meetings.
Manage patient status and monitor progress towards health goals.
Provide support for patient self-management activities and assess barriers to treatment or adherence.
Document CCM activities in the electronic health record (EHR).
Track accurate time spent on qualifying CCM services.
Ensure documentation supports billing requirements.
Assist with development of Care Plan by providing patient reported information.
Reinforce Care Plan goals with patients.
Review Care Plan and identify when updates are needed and notify providers.
Review CCM patient rosters regularly.
Identify and support patients nearing the 20-minute billing threshold.
Support implementation of CCM workflows at the site level.
Collaborate with Care Teams and Site Champions.
Assist with CCM training and meetings as needed.
Ensure CCM services align with regulatory requirements.
Participate in audits and quality improvement activities.
Maintain HIPAA compliance.
May be assigned other tasks and duties reasonably related to job responsibilities.