About us: Aizer Health, formerly Ezras Choilim Health Center, is a top-tier Federally Qualified Community Health Center providing comprehensive primary and preventative healthcare services. Our state-of-the-art technology, personnel support, and physical infrastructure help our providers deliver high-quality patient care. Our mission is to change the health of our community one interaction at a time.

We provide every patient with the highest quality of care possible and emphasize a relationship-based approach that caters to the whole person. Our rapidly growing Center offers world-class services that include Internal Medicine, Pediatrics, Acute Care, Dentistry, Optometry, Women's Health, Rehabilitation, Behavioral Health, and select specialty services.

Our Core Values: We put patients first. We are powered by our community. We are driven by collaboration. We empower success. And we nurture growth. Ensuring a diverse and inclusive workplace where we support each other and learn from each other is core to Aizer's values.

Position Overview:

We are seeking a dedicated and compassionate Chronic Care Coordinator to join our healthcare team. This unique position includes on-site responsibilities, allowing you to make a meaningful impact on our older patient population. As a member of our staff, you will play a crucial role in managing chronic conditions, ensuring patient well-being, and promoting preventive care. Your focus will be on proactive outreach, coordination, and documentation, all while meeting Medicare's Chronic Care Management (CCM) requirements.

Schedule: Mon-Fri 9am-5pm

Key Responsibilities:

• Monthly Patient Outreach:

o Reach out to eligible patients monthly via phone calls.

o Assess their well-being, address concerns, and provide education on self-management.

o Verify medication adherence, refills, and compliance with follow-up appointments/referrals.

• Chronic Condition Management:

o Ensure proper management of chronic illnesses (e.g., diabetes, hypertension, heart disease) in accordance with provider recommendations.

o Monitor symptoms, adjust treatment plans, and prevent complications.

o Coordinate care between patients and providers.

o Assume role of patient advocate and respect patient confidentially/HIPAA requirements

o Complete documentation with eClinicalWorks (EMR) of all care providers

• Preventive Care and Barriers:

o Routinely assess preventive care needs (e.g., vaccinations, screenings).

o Address barriers to care (e.g., transportation, social determinants).

o Advocate for comprehensive preventive services.

• Clear Treatment Plans:

o Initiate and review treatment plans with patients.

o Ensure understanding of therapeutics, lifestyle modifications, and preventive measures.

o Collaborate with providers to optimize care.

• Documentation and Compliance:

o Maintain accurate records of patient interactions.

o Document care plans, interventions, and outcomes.

o Ensure compliance with Medicare's CCM requirements.

Patient Accessibility:

o Be available for patient inquiries during office hours and serve as navigator.

o Ensure compliance with Medicare's CCM requirements.

• Soft Skills:

o A heart for compassionate care, especially for seniors.

o Strong assessment and communication skills.

o Excellent organizational skills and a keen eye for detail.

Basic Qualifications:

• 2 years' experience in the medical field
• Effective communication
• Comprehension and deductive reasoning
• Must have a strong commitment to a team dynamic as well as the ability to take initiative.
• Must have good communication and interpersonal skills as well as an ability to effectively relate to all medical staff and patients.

Preferred Qualifications:

• CPR certified a plus
• Phlebotomy a plus
• Electronic Medical Records experience a plus

PAY and BENEFITS:

• Salary: $20-26/Hr depending on experience.

• Medical, Dental and Vision Insurance (No employee contribution for health benefits)
• Up to 3 weeks of Paid Time Off
• 8 Paid Holidays
• Discretionary Incentive Bonus
• Short term and Long term disability
• Life/Accidental Death and Dismemberment Insurance
• 403 (b) Retirement Plan

We welcome people of different backgrounds, experiences, abilities, and perspectives. Come do your best work here at Aizer Health. Ready to make a real difference in seniors' lives? Apply today!