Patient Care Coordinator

Whole Family Health Center Inc; Town of Florida (NY); On-site; USD 45,000 - 65,000; Full time

Job summary

Whole Family Health Center Inc in Fort Pierce, Florida is seeking a Patient Care Coordinator to oversee chronic care management for up to 250 patients monthly. You will work under the Manager of Social Services and coordinate care with the care team outside face-to-face visits.

Responsibilities include eligibility determination, care plans, documentation, and collaboration with Billing, Pharmacy, and other teams to ensure quality outcomes.

Qualifications

• CMS guidelines govern CCM services.
• Experience with care coordination workflows.
• Strong documentation and data entry skills.

Responsibilities

• Coordinate CCM services per CMS guidelines.
• Verify CCM eligibility and document plans.
• Schedule patients with providers and maintain contact.
• Document health information and care plans.
• Coordinate with Billing, Pharmacy, and care teams.
• Attend monthly meetings and ensure compliance.

Skills

CMS guidelines

Microsoft Office

Communication

Medical assisting

Education

High School Diploma

Business Associate’s degree

Tools

Sage accounting software

Microsoft Applications

Job description

Patient Care Coordinator

Whole Family Health Center Inc, Fort Pierce, Florida, United States

About this position

Job Summary

The Chronic Care Management Coordinator works under the direction of the Manager of Social Services, providing services as directed by the primary care provider (MD/DO/APRN). The CCM Coordinator oversees and coordinates care for up to 250 patients enrolled in the WFHC CCM program each calendar month. Services are provided outside of face‑to‑face visits and focus on advanced primary care, supporting continuous relationships with a designated care team member to help manage and achieve quality care and positive outcomes for patients with chronic illnesses. This is a position of trust.

Communication

Good oral and written communication skills are required. Information must be exchanged with tact and persuasion. The candidate must be able to communicate with patients, staff, and other stakeholders, contributing to a positive environment. The ability to communicate in Spanish, Creole, or both is a plus.

Key Responsibilities

• Provides chronic care management services in accordance with CMS guidelines.
• Ensures patient qualifies as CCM eligible:
  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until death of patient.
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Comprehensive care plan established, implemented, revised, or monitored.
• Works closely with front desk staff to schedule patients according to visit type and provider availability.
• Provides explanation and obtains patient consent for enrollment into the program.
• Establishes monthly contact with the patient and documents required elements.
• Documentation and Service Requirements:
  • Structured recording of patient health information including problems, medications, and medication allergies.
  • Maintains a documented comprehensive electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental reassessment, and an inventory of resources.
  • Manages transitions of care and other care management services.
  • Coordinates timely sharing of patient health information within and outside the practice.
  • Provides support for chronic diseases to achieve health goals and 24/7 patient access to care and health information.
  • Provides preventative care information and schedules appointments when required.
  • Works closely with the Patient Navigator to coordinate and execute services to address needs, including federal, state, and local programs.
• Coordinates with Billing Team when billing requirements are met to ensure accurate reporting of services to payers for quality and reimbursement goals.
• Coordinates with internal and external care team members to promote quality outcomes.
• Coordinates with internal and external Pharmacy Team to ensure prescriptions are updated and medications are prepared and available for patient pickup, delivery, or mailing.
• Attends monthly meetings as scheduled.
• Communicates with providers to resolve issues related to medication management.
• Completes prior authorization for medications according to health plans.
• Initiates PAP enrollments, as requested.
• Completes prior authorization process for diagnostics and specialty services.
• Other duties as assigned.

Education and Training

• High School Diploma required; Business Associate’s degree preferred.
• Proficiency in Microsoft Applications.
• Proficiency in accounting software systems – experience with Sage accounting software a plus.

Experience

• Minimum of five (5) years of experience in medical assisting.
• Strong interpersonal skills with the ability to communicate effectively, both orally and in writing, with healthcare providers, patients, and staff at all organizational levels.
• Proficiency in computer applications, including word processing, spreadsheets, and presentation software (e.g., Microsoft Office Suite).
• Demonstrated excellence in written and verbal communication, with attention to detail and professionalism in all forms of correspondence.

Physical Requirements

• Demonstrated ability to interact effectively and respectfully with individuals from diverse backgrounds, including but not limited to race, ethnicity, nationality, sexual orientation, gender identity and expression, socio‑economic status, religion, age, English language proficiency, immigration status, and physical ability, within a multicultural work environment.
• Ability to communicate clearly and effectively in both verbal and written formats.
• Must be compliant with all required immunizations as per organizational and regulatory standards.
• Completion of a Tuberculosis (PPD) screening test required upon hire.
• Level 2 background clearance required.

WFHC reserves the right to change or modify the job description, including but not limited to Major Responsibilities, Education, Certification, and Physical Requirements.