Care Coordinator

Care Coordinator Remote

Tristate Health Pay, LLC is seeking a detail-oriented and highly dependable Care Coordinator to remotely join their team! In this role, you will support the Chronic Care Management (CCM) department and work closely with the Care Coordinator Manager and client employees to identify, coordinate, and communicate gaps in quality-of-care metrics for CCM patients.

The Care Coordinator will assist with low-risk patient navigation, preventative screening compliance, and coordination of appropriate follow-up care, while independently auditing clinical data, monitoring patient records, and educating CCM providers and practice staff on clinical quality standards and documentation requirements. The Care Coordinator will assist in developing and maintaining workflows that promote high-quality patient care, regulatory compliance, and achievement of clinical outcome metrics, while collaborating with the healthcare team to support safe, coordinated, and timely transitions of care across the healthcare continuum.

In partnership with the Care Coordinator Manager, the Care Coordinator will also be responsible for training and continually educating CCM practice staff on applicable clinical quality guidelines, workflows, and best practices to facilitate safe, effective, and high-quality patient care.

• Pay: $19 – $26/hour, offer dependent on experience

• Monday to Friday
• 8:30AM to 5PM EST
• Full time

• Ability to speak Spanish is preferred
• Maintain certification as a Certified Medical Assistant or Medical Assistant; or
• Maintain a current national or state specific licensure as Licensed Practical Nurse; or
• Maintain a current and valid Social Worker Licensure; or
• Maintain a certification by the National Board for Health and Wellness Coaching or the National Commission for Health Education Credentialing, Inc.
• Two or more years of value-based care oversight and support.
• Two or more years in an administrative review medical role.
• Experience managing medically complex adults with multiple chronic conditions.
• Experience with value-based care, quality metrics, population health, precepting, or clinical workflow improvement.

• Review clinical records to identify gaps in quality-of-care metrics and ensure documentation supports applicable CMS clinical guidelines.
• Educate and follow up with CCM patients regarding their care plans, clinical needs, and outstanding provider recommendations.
• Communicate with CCM physicians and clinical staff regarding patient status, care needs, and recommended follow-up.
• Collaborate with providers and Care Coordinators to support safe and effective patient transitions across levels of care.
• Assist in developing clinical workflows that promote compliance with CCM standards and quality-of-care metrics.
• Collect and audit medical records to ensure documentation meets CMS inclusion, exclusion, and clinical guideline requirements.
• Coordinate patient appointments, provider follow-ups, laboratory testing, diagnostics, and referrals as directed by CCM providers.
• Schedule appointments and referrals to improve patient access, continuity of care, and overall patient satisfaction.
• Utilize CCM software to document, track, and report patient outcomes, including ER, inpatient, and sub-acute utilization.

Founded on a deep understanding of healthcare operations, Tristate Health is a leading healthcare management services organization based in South Plainfield, NJ.