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Chronic Care Management Coordinator (CCM Coordinator)
Location: Wilmington, DE
Job Type: Direct Hire
Company: Stoney Batter Family Medicine Associates P.A.
Category: Non-Provider
Chronic Care Management Coordinator (CCM Coordinator) Job Description
Stoney Batter Family Medicine Associates is seeking a dedicated Chronic Care Management Coordinator (CCM Coordinator) to join our team on a full-time or part-time basis. In this pivotal role, you will play a fundamental part in supporting our CCM program, which is designed to provide comprehensive outreach and care management services to patients with multiple chronic conditions. As a CCM Coordinator, you will coordinate care, facilitate patient outreach, manage patient documentation, and work collaboratively with providers and other healthcare professionals to optimize patient outcomes.
Responsibilities
- Identify and implement appropriate interventions based on patient needs and clinical progress within the context of chronic care management.
- Maintain accurate and timely documentation, including patient notes, messaging, care plans, medication reconciliation, and scheduling notes, ensuring all information is up to date in electronic health records.
- Coordinate with healthcare providers to set patient goals, address patient needs, and adhere to program requirements to ensure optimal care delivery.
- Engage in clear communication with patients and their families regarding care goals and available resources, fostering a supportive care environment.
- Schedule and follow up on patient calls and issues, managing visit coordination and ensuring continuity of care.
- Document progress toward meeting patient goals, addressing and resolving problems as they arise in the care process.
- Coordinate care and services with external offices or providers as needed to ensure comprehensive patient support.
- Assist providers with Annual Wellness Visits (AWV) by completing patient assessment portions and ensuring all requirements are met.
- Order durable medical equipment (DME) as required for patient care plans.
- Provide virtual visits to patients when necessary, ensuring accessibility to care.
- Monitor and respond to voicemails multiple times a day to maintain prompt communication with patients and the care team.
- Support other case managers in their absence, contributing to a collaborative team environment.
- Participate in regularly scheduled meetings and team discussions as needed to stay aligned with program updates and objectives.
- Access and utilize the Aledade APP daily to review admission data and care gaps, ensuring ongoing quality improvement in patient care.
- Graduate or defer patients from the CCM program as appropriate, based on their progress and clinical status.
- Perform other related duties as assigned by management to support the overall functioning of the CCM program.
Qualifications
- 1-3 years of experience in a healthcare or care management setting is preferred.
- Strong competency in the professional healthcare services industry, with a focus on chronic disease management and patient care coordination.
- Excellent written and verbal communication skills in English, with the ability to interact effectively with patients, families, and healthcare professionals.
- Experience using hospital-based software systems and a broad knowledge of various computer software applications, including Microsoft Office products.
- Organizational skills, attention to detail, and the ability to multitask and prioritize responsibilities in a dynamic environment.
- Ability to work independently with minimal supervision and collaboratively within a team setting.
- Customer service orientation with a team player mindset and the ability to apply critical thinking to assess and resolve potential issues.
Physical Requirements
- Ability to sit and/or stand for extended periods.
- Capacity to perform work on a computer for extended periods.
- Consistent attendance and punctuality for work and meetings.
- Ability to bend and lift up to 25 lbs as needed.
- No travel required for this position.
Certifications and Education
- Certified Medical Assistant (CMA), Licensed Practical Nurse (LPN), or Certified Registered Nurse (RN) credentials are required.
Additional Information
- This CCM Coordinator role offers the opportunity to work in a supportive healthcare environment that values teamwork and continuous improvement in patient care.
- Benefits include health insurance and paid time off for eligible employees.
- Flexible scheduling options are available, including 8-hour shifts, Monday to Friday, with potential for remote or onsite work depending on organizational needs.
- Working with Stoney Batter Family Medicine Associates provides the opportunity to make a meaningful impact in chronic disease management and patient outcomes.
Stoney Batter Family Medicine Associates is committed to providing equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type. All employment decisions are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion, sex, national origin, age, disability, or any other status protected by federal, state, or local laws.