Chronic Care Coordinator

• Coordinate and monitor ongoing care for patients with chronic conditions, ensuring adherence to personalized care plans.

• Utilize CPT coding, ICD-9, and ICD-10 coding systems accurately for documentation and billing purposes.

• Collaborate with healthcare providers, social workers, and behavioral health specialists to develop comprehensive discharge planning and follow-up strategies.

• Manage medical records meticulously, ensuring HIPAA compliance and confidentiality at all times.

• Conduct intake assessments to identify patient needs and facilitate appropriate case management interventions.

• Support discharge planning processes by coordinating post-acute care services and patient education.

• Maintain thorough documentation of patient interactions, medical terminology, and treatment progress within electronic health records.

• Engage in patient service activities that promote understanding of medical conditions and foster ongoing engagement in care.

• Complete individualized patient-centered care plans and provide management services using CCM software.
• Maintain frequent patient contact to coordinate care, provide support, and ensure program compliance to improve outcomes.
• Communicate emergent needs or life-threatening episodes to Psychiatric Clinicians.

• Accurately document all verbal and written client communications in a timely manner.

• Manage a caseload of up to 500 members.

• Coordinate with schedulers to set and verify all required patient appointments.

• Manage referrals and review member medications as necessary.

• Qualify members for end-of-month billing and add them to the billing system.

• Create and update care plans and review member charts as needed.

• Proven experience working within hospital or acute care settings is highly preferred.

• Strong knowledge of medical coding practices including CPT, ICD-9, ICD-10, and medical terminology.

• Familiarity with social work principles, behavioral health integration, and pediatrics is advantageous.

• Experience in discharge planning, case management, and intake procedures is essential.

• Excellent organizational skills with attention to detail in managing medical records and documentation.

• Ability to communicate effectively with multidisciplinary teams while maintaining HIPAA compliance.

• Knowledge of hospital workflows, patient service protocols, and medical records management is desirable.

• A background in medical coding or healthcare administration will be considered an asset. Join our team to make a meaningful difference in the lives of patients managing complex health conditions through compassionate care coordination and clinical excellence!

• Strong oral, written, and phone communication skills.

• Ability to work independently with excellent organization and time management.

• Knowledge of clinical practices, diagnostic procedures, and treatment protocols.

• Strong clinical judgment and critical thinking skills.

• Ability to build trusting relationships with patients and partner practices in a fast-paced environment.

• Results-oriented with a focus on quality and daily productivity.

• Proven problem-solving, consultative, and customer service skills

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