Care Coordination Specialist - Chronic Disease Support

Holston Medical Group, PC; Kingsport (TN); On-site; USD 28,000 - 40,000; Full time

Job summary

Holston Medical Group, PC in Kingsport, TN, is seeking a Clinical Care Coordinator to outreach to patients after hospital admissions or discharges and help minimize readmission risk. You’ll educate patients on chronic conditions like hypertension, diabetes, COPD, CHF, and renal disease, coordinating with primary and specialty care teams.

The role involves scheduling appointments, maintaining clear PHI confidentiality, and tracking patient engagement to support care coordination efforts with

Qualifications

• Minimum high school diploma or equivalent.
• LPN licensed by the state or Registered/Certified Medical Assistant.
• Ability to follow protocols independently.
• Empathetic and patient with strong communication.
• Excellent time management and organization.
• Knowledge of PHI confidentiality and HIPAA basics.
• Familiarity with EHR and scheduling tools.
• Knowledge of HEDIS Gap Measures is a plus.

Responsibilities

• Outreach to patients after hospital admission/discharge.
• Educate patients on chronic conditions (hypertension, diabetes, COPD, CHF, renal disease).
• Coordinate with primary care and specialty teams for patient care.
• Schedule patient appointments and manage referrals.
• Track patient engagement in care coordination on the provided spreadsheets.
• Maintain confidentiality of patient PHI in all matters.
• Support payer scorecards and STAR rating improvement efforts.
• Generate invoices and manage program participation as needed.
• Collaborate with Eastman resources and Cigna Case Management when required.

Skills

Empathy

Excellent communication

Time management

Critical thinking

Problem solving

Interpersonal savvy

EHR proficiency

Scheduling skills

Education

LPN license

Registered/Certified Medical Assistant

Tools

EHR system

Microsoft Office

Job description

Holston Medical Group, PC in Kingsport, TN, is seeking a Clinical Care Coordinator to outreach to patients after hospital admissions or discharges and help minimize readmission risk. You’ll educate patients on chronic conditions like hypertension, diabetes, COPD, CHF, and renal disease, coordinating with primary and specialty care teams.

The role involves scheduling appointments, maintaining clear PHI confidentiality, and tracking patient engagement to support care coordination efforts with