Chronic Care & Care Coordination Specialist

Eastern-Shore-Rural-Health-System; Eastville (VA); On-site; USD 28,000 - 58,000; Full time

Job summary

Eastern-Shore-Rural-Health-System is hiring a Case Management Specialist based in Eastville, VA. The role works with providers, patients, and insurance companies to ensure high-quality care and adherence to care plans.

The position involves coordinating with community partners and utilizing EMR for care coordination, with occasional travel to OCHC 1-2 days per week. The incumbent will manage transitions of care, monitor quality measures, and conduct extensive outreach efforts, including a high

Qualifications

• LPN/RN license with clinical experience required, or MA certification with minimum 5 years clinical experience in a medical setting.
• Clinical experience with chronic disease management understanding and knowledge of all life cycles.
• CPR certified current.
• Proficient in Microsoft Excel and computer skills; professional and detail oriented.

Responsibilities

• Identify patients at risk for attribution loss and coordinate care to improve engagement and self-care.
• Monitor ER/discharge reports to identify high-risk patients and coordinate care.
• Initiate daily transitions of care visits.
• Close care gaps to improve UDS and HEDIS quality measures.
• Generate at least 750 telephone encounters annually; Medicare outreach targets 150/month.

Skills

Microsoft Excel

Communication

Teamwork

Customer service

Computer skills

Education

High school

Tools

EMR systems

Job description

Eastern-Shore-Rural-Health-System is hiring a Case Management Specialist based in Eastville, VA. The role works with providers, patients, and insurance companies to ensure high-quality care and adherence to care plans.

The position involves coordinating with community partners and utilizing EMR for care coordination, with occasional travel to OCHC 1-2 days per week. The incumbent will manage transitions of care, monitor quality measures, and conduct extensive outreach efforts, including a high