Chronic Care Coordinator — LPN/MA, On-site

Fortiscares; Marietta (GA); Hybrid; USD 42,000 - 64,000; Full time

Benefits offered by this job

Health reimbursement account

401(k) plan after first year

Paid Vacation, Paid Sick Time, 10 Paid

Set schedule, no weekends

Family-friendly work environment

Job summary

Fortis Care is seeking a Care Coordinator to support patients with complex medical needs, under the supervision of the Manager, Chronic Care Management. The role emphasizes patient engagement, care planning, and follow-up to prevent hospitalizations and improve outcomes.

The ideal candidate holds an LPN or CMA credential, has 1–2 years in chronic care management, and can work on-site five days a week with some remote afternoons. Proficiency with EHR systems and strong communication are required.

Qualifications

• Must be a Licensed Practical Nurse (LPN) or Certified Medical Assistant (MA).
• 1–2 years of experience in chronic care management, primary care, ambulatory care, skilled nursing, or hospital settings.
• Associate’s degree or higher in a clinical or health-related field preferred.
• Experience with care management documentation and EHR systems preferred.

Responsibilities

• Deliver chronic care management services to patients with complex or high-risk conditions.
• Conduct assessments of medical, educational, and psychosocial needs using standardized tools.
• Collaborate with providers, specialists, and families to support development and updates of individualized care plans.
• Identify and prioritize patients for medical services each day and prep charts for efficient visits.
• Provide patient and family education focusing on self-management and self-care.
• Coordinate care transitions, including post-hospital follow-up, reconciliation, and discharge education.
• Document all care management activities accurately and timely.
• Participate in process improvement activities and quality initiatives.

Skills

Chronic disease mgmt

Communication skills

Cultural competence

Organizational skills

Independent work

Problem solving

Education

LPN or CMA

Associate degree or higher (clinical/health-related)

Tools

EHR systems

Job description

Fortis Care is seeking a Care Coordinator to support patients with complex medical needs, under the supervision of the Manager, Chronic Care Management. The role emphasizes patient engagement, care planning, and follow-up to prevent hospitalizations and improve outcomes.

The ideal candidate holds an LPN or CMA credential, has 1–2 years in chronic care management, and can work on-site five days a week with some remote afternoons. Proficiency with EHR systems and strong communication are required.