Chronic Care Coordinator

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Full Time Regular Hardwick, VT, US

5 days ago Requisition

Salary Range: $24.00 To $34.00 Hourly

Job Summary:

A Chronic Care Coordinator I provides comprehensive support and guidance to patients with chronic illnesses, ensuring they receive appropriate care and resources to manage their conditions effectively. They act as a central point of contact, coordinating care between patients, healthcare providers, and community resources. The role involves developing and implementing personalized care plans, monitoring patient progress, and facilitating communication to improve patient outcomes.

Supervisory Responsibilities:

This position has no direct supervisory responsibilities.

Essential Job Functions/Responsibilities:

• Provides patient-centered, basic, short-term case management for medically and/or socially complex patients as below:
  • Meets with patients for face-to-face and/or telephone contacts in order to facilitate success with self-management goals.
  • Assesses patient for goals of care and barriers to care.
  • Follows up with patients and pharmacies to be sure patients are filling and taking their medications as prescribed.
  • Tracks and follows up on referrals to diagnostic testing, specialists, and health education (diabetes educators, dietitians, asthma educators, etc.), and to behavioral health specialists or other behavioral health providers.
  • Proactively follows up with Health Center patients who have received inpatient or Emergency Department services at local hospitals, in accordance with Health Center protocols. This involves ensuring a seamless transition of care by coordinating with hospital staff, scheduling follow-up appointments, and addressing any additional needs the patients may have.
  • Connects patients to support services as needed both externally and internally as a Health and Wellness resource.
  • Reminds patients of appointments and collects information prior to appointments.
  • Follows up with providers and patients to schedule patients for medical care per Health Center protocols.
  • Provides patient/family education and instruction on issues of health maintenance and management of chronic conditions, provides patients/families with educational materials for self-management in a manner most appropriate to their learning.
• Coordinates patient care with external disease management and/or care management organizations.
• Is an active member of the Community Health Team (CHT), helping to coordinate care for people with complex or chronic conditions.
• Works closely with Department of Vermont Health Access (DVHA) for patients who are served by both the Health Center and DVHA.
• Performs outreach and care management duties for patients who are considered high risk or very high risk by the Accountable Care Organization.
• Interacts and collaborates with multiple agencies to formulate and document shared care plans with and for patients.
• Facilitates team based care by being a bridge between the patient, the practice and the community. This may include coordinating and facilitating Care-Team Meetings.
• Assists in defining site-level protocol to identify patients who may benefit from care management based on criteria such as:
  • Behavioral health conditions.
  • High cost/high utilization.
  • Poorly controlled or complex conditions.
  • Social determinants of health.
  • Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff, patient/family/caregiver
• For patients identified for care management, consistently uses patient information and collaborates with patients/families/caregivers to develop a documented care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.
• Participates in Health Center panel management and Population Health Initiatives
• Assists in identifying and providing outreach to patients who are due or overdue for appointments, lab tests, eye examinations, chronic condition procedures, etc. per health center protocol.
• Reviews panel reports regularly.
• Works with the…