Chronic Care Coordinator - Marshall Internal Medicine

Marshall Health; Huntington (VA); Hybrid; USD 55,000 - 75,000; Full time

Job summary

Marshall Health in Virginia is seeking a Care Coordination Specialist to assist physicians and the care team in identifying patients in their panel who may benefit from CCM services and to advocate for access to needed care.

The role supports primary and subspecialty co-management through timely communication, collecting outside records, updating care plans, and documenting activities in the EHR to meet CCM requirements and improve patient outcomes.

Responsibilities

• Assists physicians and other healthcare providers in identification of patients in their panel that may be eligible for services available. Coordinates care by serving as the advocate and resource for the patient.
• Supports primary care and sub-specialty co-management with timely communication, follow-up and integration of the patient's chronic care management. Obtains outside records from specialists or other referrals/care settings.
• Assists Chronic Care Manager to measure patient outcomes, review case loads, and identify any work flow issues. Works with providers to redesign care processes and improve quality.
• Works with patients, care-givers and providers/care team members, specialists, and community-based resources to update and execute the care plan to help patients meet goals outlined in the shared care plan.
• Provides outreach calls to patients enrolled in programs and documents in EHR to ensure compliance with CCM program requirements. Listens to patients and care-givers to address health issues and supports compliance with recommendations made by specialists. Facilitates patient access to care based upon the needs of the patient and family.
• Provides patient education related to specific chronic diseases. Works with providers to develop and implement patient education sessions.
• Performs other duties as assigned or requested.

Job description

Job Responsibilities

• Assists physicians and other healthcare providers in identification of patients in their panel that may be eligible for services available. Coordinates care by serving as the advocate and resource for the patient.
• Supports primary care and sub-specialty co-management with timely communication, follow-up and integration of the patient's chronic care management. Obtains outside records from specialists or other referrals/care settings.
• Assists Chronic Care Manager to measure patient outcomes, review case loads, and identify any work flow issues. Works with providers to redesign care processes and improve quality.
• Works with patients, care-givers and providers/care team members, specialists, and community-based resources to update and execute the care plan to help patients meet goals outlined in the shared care plan.
• Provides outreach calls to patients enrolled in programs and documents in EHR to ensure compliance with CCM program requirements. Listens to patients and care-givers to address health issues and supports compliance with recommendations made by specialists. Facilitates patient access to care based upon the needs of the patient and family.
• Provides patient education related to specific chronic diseases. Works with providers to develop and implement patient education sessions.
• Performs other duties as assigned or requested.