Job Description

PRIMARY ACTIVITIES/DUTIES:

• Care Coordinators assist patients with managing their blood pressure by daily monitoring and calls.
• As a Care Coordinator, you will have an assigned group of patients to follow up with monthly via phone.
• Conversations include reviewing daily blood pressure readings, educating patients on improving hypertension control, and assisting patients to supporting the plan of care established by their provider.
• Verify and record the patient’s demographics, medical issues, medications, and risk management factors to create a clinical summary using specialized medical software.
• Contact patients when blood pressure exceeds established parameters to evaluate the situation.
• Communicate with practices and/or providers, based on established protocols, when readings exceed established parameters.
• Help provide the patient with a means to make timely contact with healthcare practitioners in the practice who can address any urgent needs about their hypertension.
• Responsible for registering chronic care management and principal care management.
• Complies with documentation requirements of CCM and PCM program by carrying out the care plan with patient, family/caregiver and providers and recording in the EMR.
• Monitor adherence to care plans, evaluate effectiveness, monitor patients progress in a timely manner and facilitate changes as needed.
• Provides patient health counseling, education, and instruction.
• Ability to follow HIPAA guidelines.
• Handle potentially difficult conversations calmly and professionally.
• Participate in individual & Group projects as directed by management.
• Complete audits of Chronic Kidney Disease Patients to ensure patients have appointments scheduled.
• Other duties, as assigned

Qualifications

• Able to communicate with customers at all levels
• Must be computer literate with a high comfort level with computers and computer programs
• MS Word, MS Excel, Email and Internet
• Candidate must be able to speak on the telephone intermittently throughout the day
• Candidate must be able to read and write English fluently
• Candidate must be able to provide and confirm a safe home office environment
• Home office must be HIPAA compliant
• Must be able to meet home internet and phone requirements

WORK EXPERIENCE:

• Minimum of 1–3-year work experience in healthcare setting involving patients with complex chronic disease states preferred.
• Previous call experience with U.S. based clients.
• Must be PC proficient and able to thrive in a fast-paced setting; experience in Microsoft Office Suite: Outlook, Word and Excel a must.

License/Certifications

• CNA, MA, CMA, RMA, or CCMA (Required)

SKILLS

• Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure and basic medical management of these states.
• Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management skills.
• Strong organizational and interpersonal skills
• Excellent customer service skills demonstrated by positive feedback from patients/team.
• Ability to identify problems and recommend solutions.
• Ability to read, write and communicate effectively orally and in writing.
• Basic computer skills including previous work with an electronic health record (EHR)

Language