Chronic Care Coordinator
CurrentPerforms telephonic outreach to an identified population with chronic diseases, including, but not limited to: diabetes, asthma, hyperlipidemia, heart failure, hypertension, etc. in an effort to improve the quality of their careUtilizes database to track patients in the Chronic Care Management (CCM) program with upcoming care plans that are due for renewal, patients who need a post-visit follow up performed, patients who are eligible for the CCM program, etc.Obtains patient consent and creates an annual patient driven care plan based on health goals that the patient, with the help of their primary care provider, sets for their chronic conditions indicated in their active problem listProvides an effective communication link between patients, medical staff, and other providersPerforms timely follow up calls and collects health information through patient outreachEvaluates 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-managementCoordinate and collaborates with medical staff involved in the care of the patient; ensuring all preventative health opportunities are discussed and conducted, as appropriateAssist in coordination of care with primary care physician, specialists, patient, insurance companies, and other providers in the community.Maintains accurate and complete documentation within the EMR, Central Worklist, and other electronic databasesMeets with office staff monthly to provide updatesParticipates in monthly CCM team meetingsReports information regarding quality improvement activities to Patient Care Coordinator for care gap closure
