Care Coordination Specialist - Chronic Care & EMR Liaison

Eastern-Shore-Rural-Health-System; Onley (VA); Vor Ort; USD 42.000 - 87.000; Vollzeit

Zusammenfassung

Eastern-Shore-Rural-Health-System is seeking a Case Management Specialist to coordinate chronic and preventive care across the continuum, collaborating with providers, patients and insurers. Based at FCHC in Onley, VA, the role requires clinical credentials and EMR proficiency.

You will identify at-risk patients, manage transitions of care, track outcomes, and work with community partners to reduce hospitalizations while improving care quality. Travel to OCHC 1-2 days weekly may be expected.

Qualifikationen

• LPN/RN license with clinical experience or MA certification with 5+ years in a medical setting.
• Clinical understanding of chronic disease management and life cycles.
• Proficient with Microsoft Excel.
• Strong communication, teamwork, and customer service skills.
• CPR certification required.
• Valid driver's license and reliable transportation.
• Bilingual abilities a plus.

Aufgaben

• Identify patients at risk for attribution loss and coordinate care.
• Monitor ER/discharge reports to support high-risk patients and care coordination in the EMR.
• Initiate daily transitions of care visits.
• Close care gaps to improve UDS/HEDIS quality measures.
• Generate at least 750 telephone encounters annually.
• Collaborate with community partners and healthcare teams within the EMR.
• Attend minimum two community events per year.

Kenntnisse

Clinical experience

Chronic disease management

Customer service

Communication

CPR certification

Driver's license

Ausbildung

High school

Tools

Microsoft Excel

Jobbeschreibung

Eastern-Shore-Rural-Health-System is seeking a Case Management Specialist to coordinate chronic and preventive care across the continuum, collaborating with providers, patients and insurers. Based at FCHC in Onley, VA, the role requires clinical credentials and EMR proficiency.

You will identify at-risk patients, manage transitions of care, track outcomes, and work with community partners to reduce hospitalizations while improving care quality. Travel to OCHC 1-2 days weekly may be expected.