Chronic Care Coordinator

Job Description

Job Description

Chronic Care Coordinator

Center for Primary Care

Who we are :

For over 30 years the Center for Primary Care (CPC) has cared for families in the CSRA by providing patients with the most convenient, accessible, and personal healthcare available. Our mission is to improve the health and wellbeing of the families we serve by providing compassionate and high-quality care in a joyful setting. The physicians, healthcare professionals, and support team at our 9 practices, plus laboratory, imaging, and corporate locations work to transform our mission into action.

What our employees say :

At Center for Primary Care, we understand that the work environment is as important as the hard work you do. Center for Primary Care is Great Place to Work Certified which means our employees share feedback on their work culture experiences and we listen and strive to create positive employee experiences centered on joy, trust, and belonging.

Learn more about CPC's culture and Great Place to Work Certification by clocking on the link below :

Working at Center for Primary Care | Great Place To Work

Benefits for you and your family :

Coverage that cares for body, mind, and spirit.

Comprehensive benefits, extensive networks, and no charge medical visits at Center for Primary Care locations. Retirement plan with generous employer match and profit sharing.

Mental Health Support Services.

Paid Time Off programs.

Scheduled Bonuses.

Chronic Care Coordinator

Key Responsibilities :

Essential Functions

The Chronic Care Coordinator conducts patient outreach and is responsible for monitoring patient health status, review patients' conditions and symptoms, evaluation of patients' compliance with physician directed care, and orchestrating seamless care for patients.

Provides an effective communication link between patients, medical staff, and other providers

Performs timely follow up calls and collects health information through patient outreach

Evaluates areas of concern, and assists patients with their health care needs, including medical record retrieval, psychosocial support, community resources, medication assistance, etc.

Provides ongoing education and outreach to support patient's achievement of self-management

Coordinate and collaborates with medical staff involved in the care of the patient; ensuring all preventative health opportunities are discussed and conducted, as appropriate

Assist in coordination of care with primary care physicians, specialists, patients, insurance companies, and other providers in the community.

Maintains accurate and complete documentation within the EMR, and other electronic databases

Meets with office staff monthly to provide updates

Reports information regarding quality improvement activities for any care gap closure

All essential functions must be performed. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functions. The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified. Examples listed do not preclude the performance of other duties similar in nature or in level of complexity.

Qualifications for Success :

Education, License / Certification, and Experience Requirements

Education : High School Diploma or equivalent License / Certification : Medical Assistant Certification

Experience : 1-2 years of Medical Assistant or similar medical experience

Strong working medical knowledge of the clinical needs and disease processes for the chronically ill population

Knowledg