Chronic Care Coordinator

We are looking for a Chronic Care Service Representative to work remotely from anywhere in the US. This role will require you to provide telephone Chronic Care Management for patients throughout the health system under the direction of the patient’s physician. The representative utilizes the defined process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures, and guidelines. Provides high-risk patients with chronic disease management and liaises between the patient, hospital, physicians’ office, home care agency, etc. This position is telephonic care coordination as directed by the patient’s physician.

Responsibilities

• Assess patient’s needs for services and cooperatively develop an integrated patient-centered care plan and goals with the patient/family and other providers
• Coordinate transitional care from an inpatient service to other settings as per the care plan
• Work collaboratively with team members to provide outreach and engagement
• Provide assistance through advocacy to patients and families for entitlements and other community services
• Work closely with in-office providers to manage the day-to-day calls involving: symptom control, and medication management, and provide patient and family education
• Receive triage and respond to telephone calls from patients requiring medical guidance
• Provides patients with clear instructions and education utilizing appropriate guidelines
• Directs patient to keep follow-up appointments with physician's office and to maintain self-home care based on physician direction and outcomes of the nursing assessment
• Utilizes the in-office staff, and Clinical Call Center to meet the needs of the patient and family
• Documents call according to established guidelines
• Communicates with physician, Nurse Practitioner, RN, Social Worker, or other health care providers regarding patient’s status
• Collaborates with the Nurse Practitioner, and or physician when a patient requires intervention or follow-up
• Participates in education and in-service programs.
  
  

Qualifications

• Minimum 2 years of experience in US healthcare role
• Previous experience in a patient support role is a plus
• Familiarity with EHR systems and practices
• Customer focus and adaptability to different personality types
• Ability to multi-task, set priorities and manage time effectively
• A bachelor's degree
• Customer-oriented attitude with professionalism.
• Excellent communication and listening skills with good command of the English language.
• Experience in Voice Process