Chronic Care Coordinator - Onsite 5 Days, Remote Afternoons

Fortis-Care; Marietta (GA); Hybrid; USD 48,000 - 64,000; Full time

Benefits offered by this job

Health reimbursement account

401(k) plan

Paid vacation

Paid sick time

No weekends

Family-friendly

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. You will work directly with patients, providers, and care teams to ensure coordinated, patient-centered care with a focus on engagement, care planning, and follow-up to prevent hospitalizations.

The role emphasizes collaboration with providers and families to develop and update individualized care plans, perform assessments, and ensure accurate

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.
• Preference given to those with skilled nursing setting experience.

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 of individualized care plans.
• Identify and prioritize patients for medical services daily, 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 and medication reconciliation.
• Document all care management activities accurately and timely.
• Participate in process improvement and quality initiatives.

Skills

Chronic disease mgmt

Communication skills

Empathy & patient engagement

Organizational skills

Independent collaboration

Education

Associate degree or higher in clinical/health field

Tools

EHR systems experience

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. You will work directly with patients, providers, and care teams to ensure coordinated, patient-centered care with a focus on engagement, care planning, and follow-up to prevent hospitalizations.

The role emphasizes collaboration with providers and families to develop and update individualized care plans, perform assessments, and ensure accurate