Chronic Care Management Coordinator – Full-Time

Haskell Memorial Hospital; Town of Texas (WI); Hybrid; USD 60,000 - 85,000; Full time

Benefits offered by this job

Insurance options

FSA/HSA

TCDRS Retirement

PTO

Job summary

Haskell Memorial Hospital is seeking a Chronic Care Management Coordinator to support disease management and lifestyle coaching for patients, under the supervision of the Regional CCM Coordinator.

The role emphasizes CMS/Medicare compliance, care plan development in EMR, and coordination across care teams. Remote opportunities may be available depending on clinic needs; strong communication and teamwork are essential.

Qualifications

• Coaching education and training preferred.
• Experience with patient engagement, coaching, and patient education preferred.
• Strong communication and teamwork skills required.
• HIPAA compliance and patient confidentiality must be maintained.

Responsibilities

• Identify eligible Medicare CCM patients and obtain consent.
• Develop and update patient-centered care plans in EMR.
• Provide at least 20 minutes of non-face-to-face care management time monthly.
• Document all activities in CMS-compliant time tracking.
• Coordinate transitions and follow-up with primary care providers.

Skills

Coaching

Patient engagement

Education

Communication

Teamwork

HIPAA compliance

Time management

Empathy

Tools

EMR

Job description

Chronic Care Management Coordinator - Full-Time

Haskell Memorial Hospital is seeking a motivated individual for the role of Chronic Care Management coordinator (CCM coordinator).

POSITION SUMMARY

The Chronic Care Management coordinator (CCM coordinator) will work collaboratively and under the direction of the Regional CCM Coordinator. In collaboration with the Regional CCM Coordinator, the CCM coordinator is responsible for providing disease management and healthy lifestyle coaching, education, training, and motivational support to patients, referral management and community resource management to encourage quality outcomes, smooth transitions, and coordination of care across the health continuum. The MA encourages healthy lifestyle choices to prevent and reduce long term effects of chronic illness. This position also ensures compliance with CMS/Medicare requirements for Chronic Care Management, including patient eligibility, consent, time tracking, and documentation of care plans and interventions.

QUALIFICATIONS

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

1. Coaching education and training preferred

2. Previous clinical experience including working with the geriatric population preferred

3. Previous work experience with patient engagement, patient coaching, and patient education preferred

• Report to the clinic or maintain a fully functional home office; remote opportunities depend on clinic needs.
• Represent the clinic with professionalism and compassion in all communications.
• Deliver exceptional customer service and timely responses to patients and providers.
• Be independent, proactive, and a strong team player who goes above and beyond.
• Treat all patients with dignity and respect, ensuring each concern is addressed quickly and appropriately.
• Communicate clinical updates with patients and providers in a timely, patient-centered manner.
• Ensure accurate time tracking and documentation for all CCM activities in compliance with Medicare guidelines.
• Maintain strict patient confidentiality and follow HIPAA guidelines at all times.
• Balance work and personal life effectively by staying fully committed during paid work hours.
• Ask for help when needed-teamwork and mutual support are core values.

JOB DUTIES

• Other duties as assigned.
• Exhibit competence consistent with the level of training and education in the Seven Domains of Care Coordination in the primary care setting:
  • Population Health Management,
  • Comprehensive Assessment and Care Planning,
  • Interpersonal Communication,
  • Education/Coaching,
  • Health Insurance and Benefit knowledge,
  • Community Resource knowledge and
  • Research and Evaluation skills.
• Key Responsibilities:
  • Identify eligible Medicare patients (with two or more chronic conditions expected to last at least 12 months) and obtain documented patient consent for CCM services.
  • Develop, implement, and regularly update a comprehensive, patient-centered care plan in the electronic medical record.
  • Provide at least 20 minutes of non-face-to-face clinical staff time per month directed by a physician or qualified health care professional.
  • Document all time spent and services provided in compliance with CMS billing requirements.
  • Conduct regular outreach, education, and disease management support for patients with chronic conditions.
  • Support patients in achieving personal health goals and adherence to their care plans.
  • Coordinate care transitions, including hospital, rehab, or emergency room discharges, ensuring timely follow-up with the primary care provider.
  • Collaborate with providers, specialists, and community resources to promote continuity of care.
  • Monitor patient progress, update care plans, and communicate variances to supervising clinicians.

COMPANY DESCRIPTION

Haskell Memorial Hospital is a critical access hospital located in Haskell, Texas. We offer inpatient/outpatient services, including acute inpatient care, inpatient rehab/swing bed program, 64-slice CT, MRI, physical therapy, a rural health clinic, pain management, cardiac and pulmonary rehab, respiratory therapy, and an emergency department. The hospital prides itself on providing high-quality, compassionate patient care to Haskell County and the surrounding region since 1939.

BENEFITS

• Haskell Memorial Hospital offers a generous benefits package for full-time employees, including a variety of insurance options, FSA/HSA, TCDRS Retirement, and PTO. HMH is an EEO.