Chronic Care Coordinator - Marshall Internal Medicine

Job Responsibilities:

• Assists physicians and other healthcare providers in identification of patients in their panel that may be eligible for services available.  Coordinates care by serving as the advocate and resource for the patient. 
• Supports primary care and sub-specialty co-management with timely communication, follow-up and integration of the patient's chronic care management.  Obtains outside records from specialists or other referrals/care settings.
• Assists Chronic Care Manager to measure patient outcomes, review case loads, and identify any work flow issues.  Works with providers to redesign care processes and improve quality. 
• Works with patients, care-givers and providers/care team members, specialists, and community-based resources to update and execute the care plan to help patients meet goals outlined in the shared care plan. 
• Provides outreach calls to patients enrolled in programs and documents in EHR to ensure compliance with CCM program requirements.  Listens to patients and care-givers to address health issues and supports compliance with recommendations made by specialists.  Facilitates patient access to care based upon the needs of the patient and family.
• Provides patient education related to specific chronic diseases.  Works with providers to develop and implement patient education sessions. 
• Performs other duties as assigned or requested.