Chronic Care Coordinator - Marshall Internal Medicine

Marshall Health; Huntington (VA); On-site; USD 50,000 - 70,000; Full time

Job summary

Marshall Health in Huntington, VA is searching for a Chronic Care Coordinator to assist in managing care for patients with chronic diseases. This role includes coordinating care, educating patients, and ensuring compliance with care plans.

The ideal candidate will have a nursing or medical assisting background, with experience in primary care settings preferred. This position requires strong communication skills and a commitment to patient advocacy.

Qualifications

• Graduate from a nursing or medical assisting program.
• Must obtain relevant certifications or licenses.
• Experience in a primary care setting preferred.

Responsibilities

• Assist physicians in identifying eligible patients for services.
• Support communication and integration of patient care.
• Work with care team to meet patient goals.
• Provide patient education on chronic diseases.
• Document outreach and compliance in EHR.

Skills

Patient advocacy

Chronic disease management

Communication

Care coordination

Education

Graduate of a school of nursing or medical assisting program

Job description

Chronic Care Coordinator - Marshall Internal Medicine

1249 15th St, Huntington, WV 25701, USA

Job Description

Posted Thursday, June 18, 2026 at 4:00 AM

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 workflow issues. Works with providers to redesign care processes and improve quality.
• Works with patients, caregivers 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 caregivers 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.

Education: Graduate of a school of nursing or medical assisting program. MA candidates must be able to obtain certification. LPN candidates must hold, or be able to obtain, a valid WV license.

Experience: Experience in a primary care setting preferred.