Onsite Care Management Coordinator

Job Description

Job Description

Care Management Coordinator (Patient-Facing)

Reports To : Director of Clinical Services

Employment Type : Hourly / Full-time

Position Summary

The Care Management Coordinator engages directly with patients to support ongoing care management programs, including Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Principal Care Management (PCM), Remote Therapeutic Monitoring (RTM), and others. This role focuses on building rapport, providing education within scope, maintaining active care plans, and ensuring timely follow-up for patients with chronic and complex care needs. Responsible for facilitating quality care in accordance with established clinical practice guidelines and protocol and PCP direction. Fosters patient engagement and adherence to plan of care to achieve evidence based clinical objectives and goals specific to chronic conditions and preventive health measures.

Key Responsibilities

• Conduct monthly and as-needed outreach calls to patients enrolled in Care Management Programs
• Educate patients and families on preventive care, medication adherence, healthy lifestyle choices, and self-management techniques to empower them in their own care.
• Facilitate communication between patients, physicians, specialists, and other healthcare providers to ensure seamless and cohesive care. Communicate relevant updates to providers and the interdisciplinary care team
• Develop and maintain personalized care plans based on patient needs and goals, including measurable treatment goals and planned interventions.
• Assist patients with finding and accessing community resources, social services, and other supports to address social determinants of health and improve overall well-being (e.g., transportation, food security, housing, safety, financial concerns)
• Assist patients with scheduling recommended follow-ups, screenings, and preventive visits.
• Maintain accurate and timely documentation of care management activities in the electronic health record (EHR) system, including patient consent and comprehensive care plans in accordance with CMS and organizational requirements.
• Utilize Remote Patient Monitoring devices and technology to monitor vital signs and activity levels.
• Perform administrative tasks related to the program, such as ensuring compliance with billing requirements and generating reports
• Track and log all patient interactions and care coordination time for billing compliance.
• Monitor symptoms, vital signs, and other patient-reported outcomes; escalate clinical concerns to providers as appropriate.
• Participate in team huddles, case reviews, and quality improvement projects.
• Assist with patient recruitment and enrollment into care management programs.
• Work toward closing care gaps identified by quality measure reporting.

Qualifications

Required