Clinical Care Coordinator

Holston Medical Group Career•Kingsport, TN

About The Position

The Clinical Care Coordinator conducts outreach to patients after a recent hospital admission or discharge, addresses patient needs, and helps minimize the risk of readmission. The coordinator educates patients about chronic conditions, including hypertension, diabetes, COPD, CHF, and renal disease, and responds to care coordination referrals from primary care providers. Acting as a liaison between patients and their primary or specialty care providers, the coordinator arranges appointments and tracks patient engagement and enrollment in care coordination programs. The role also includes reviewing patient charts and payer scorecards for HEDIS gaps in care, coordinating follow-up and documentation, and supporting efforts to improve the organization’s STAR ratings. For eligible patients, the coordinator reviews program criteria and supports potential enrollment in Eastman hypertension or diabetes programs, including patient education, follow-up, invoicing, tracking, and coordination with onsite Eastman resources and Cigna Case Management. The position requires a high school diploma or equivalent and either an LPN license in the state of employment or Registered/Certified Medical Assistant credentials. The coordinator must work independently while following protocols, communicate effectively and compassionately with patients and colleagues, and have strong organizational, time management, critical-thinking, and problem-solving skills. The role involves frequent computer and office-equipment use and remaining stationary for at least 75% of the time. Reasonable accommodations may be made for individuals with disabilities.

Requirements

High school diploma or equivalent.
LPN license in the state of employment, or Registered/Certified Medical Assistant credentials.
Ability to work independently while adhering strictly to protocols and remaining accountable.
Empathy and patience when working with patients and their families.
Excellent written and oral communication skills.
Strong time management, organizational, critical-thinking, and problem-solving skills.
Proficiency with EHR systems and scheduling.
Basic knowledge of Microsoft Office.
Knowledge of HEDIS gap measures.
Ability to remain stationary for at least 75% of the time.
Ability to operate a computer and office productivity equipment, including a calculator, copy machine, and computer printer.
Ability to manage frequent interruptions, changing tasks, and shifting priorities.
Ability to establish cooperative working relationships and interact appropriately with colleagues and patients in different contexts.
Ability to move objects up to 10 pounds as part of sedentary work and occasionally move objects up to 20 pounds as part of light work.

Responsibilities

Build close relationships with patients to improve compliance with treatment recommendations and management plans.
Communicate with providers and coordinate care with patients.
Maintain confidentiality of patient health information.
Review patient charts for information that can attest to HEDIS measures and contact patients to discuss gaps in care.
Coordinate and schedule appointments to address gaps in care and other patient needs.
Review payer scorecards and collaborate with Operations Management, the Manager, or the Clinical Care Coordinator Team Lead on opportunities to improve the group’s STAR rating.
Ensure appropriate documentation and results are recorded in the EHR and complete manual attestations in payer systems for HEDIS gap reporting.
Pull eligible patient lists and review charts to determine potential eligibility for Eastman hypertension or diabetes programs; coordinate potential enrollment with the Program Director and track enrolled patients.
Generate and send monthly and biannual invoices to Eastman for enrolled patients.
Schedule follow-up visits and educate patients about hypertension and diabetes.
Coordinate with onsite Eastman resources to continue patient education and disease management, make appropriate referrals to Cigna Case Management, and provide a weekly outreach list to the Manager or Clinical Care Coordinator Team Lead for reporting to Cigna Eastman insurance.
Track patient engagement and enrollment in Care Coordination using tracking spreadsheets.
Outreach to patients following hospital admission or discharge, address needs, and help reduce readmission risk.
Educate patients about chronic disease states, including hypertension, diabetes, COPD, CHF, and renal disease.
Respond to care coordination referrals from primary care providers and serve as a liaison between patients and their assigned primary or specialty care providers.