Patient Chronic Care Program Coordinator

Saint Francis Health System•Warren Clinic - Monkey Island, NC

3d•Onsite

About The Position

The Patient Chronic Care Program Coordinator is responsible for coordinating and managing care for patients with multiple chronic conditions. This role supports improved patient outcomes through care planning, patient education, care transitions, medication management, and ongoing communication with patients, providers, caregivers, and community resources. The coordinator helps ensure compliance with Medicare Chronic Care Management requirements and promotes quality, patient-centered care.

Requirements

High school diploma or GED.
Minimum 3 years in medical related field.
Knowledge of chronic disease processes, treatment plans, and evidence-based care management practices along with Medicare Chronic Care Management, Principal Care Management, Transitional Care.
Excellent communication skills, both written and verbal that present clear and concise information.
Strong patient assessment and care planning skills.
Skilled in care coordination, case management, and follow-up activities.
Ability to educate and motivate patients toward self-management of chronic conditions.
Ability to maintain confidentiality and exercise discretion when handling sensitive patient information.
Ability to recognize changes in patient status and appropriately escalate concerns to providers and coordinate multiple aspects of patient care across healthcare settings and adapt to changing healthcare regulations, organizational priorities, and patient needs.
Ability to work independently and collaboratively in a fast-paced environment, managing multiple priorities with competing deadlines.

Responsibilities

Identifies and enrolls eligible patients in Chronic Care Management programs.
Develops, implements, and updates comprehensive patient-centered care plans.
Conducts monthly patient outreach and documents non-face-to-face care management services.
Monitors patient progress toward health goals and address barriers to care.
Coordinates referrals, diagnostic testing, specialist appointments, and community services.
Assists patients with medication adherence and understanding treatment plans.
Educates patients and families regarding chronic disease management, preventive care, and healthy lifestyle choices.
Facilitates communication between patients, providers, specialist and hospital.
Supports care transitions following emergency department visits, hospitalizations, or skilled nursing facility stays.
Maintains accurate documentation in the electronic health record.
Monitors quality metrics and participate in quality improvement initiatives.
Ensures compliance with Centers for Medicare and Medicaid Services, Medicare, Rural Health Clinic, Health Insurance Portability and Accountability Act, and organizational policies.