Care Coordinator - Chronic Management

About the role

This is an in-office phone and EMR-based coordination role — not a traditional clinical floor position. As a Care Coordinator in our growing CCM program, you'll work directly with patients living with chronic conditions (such as diabetes, hypertension, COPD, and heart disease), helping them stay on track with their care plans and health goals through regular outreach and follow-up.

Responsibilities

• Developing personalized care plans in collaboration with patients, caregivers, and healthcare providers.
• Cooking up and facilitating communication between various healthcare team members, including physicians, specialists, nurses, and ancillary service providers.
• Monitoring patients' adherence to treatment plans and medications, as well as their progress towards health goals.
• Providing ongoing education and support to patients and their families regarding disease management, lifestyle modifications, and preventive care measures.
• Utilizing electronic health records (EHR) and other healthcare technology tools to document patient encounters, track interventions, and ensure continuity of care.
• Collaborating with community resources and social services agencies to address patients' social determinants of health and support their overall well-being.
• Conducting regular follow-up check-ins and care coordination activities to optimize health outcomes and quality of life for patients with chronic conditions.

Qualifications

• At least 1 year of clinical work experience as a Medical Assistant.
• At least 1 year of EMR experience; eClinicalWorks preferred.
• A high level of professionalism.
• Excellent written and verbal communication skills.
• Strong customer service skills.
• A Medical Assistant Course Completion Diploma or CMA designation required.
• Bilingual (English/Spanish) is a plus.
• Must have HS diploma or GED equivalent.