Chronic Care Management Coordinator
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Job Location:
Atlanta, GA - USA
Hourly Salary:
USD 17 - 32
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
Why Fortis Care
At Fortis Care we believe every patient deserves attentive high-quality care delivered where they are. Our physician-led team partners with nursing facilities to provide expert consistent and compassionate medical services right at the bedside.
We take a holistic approach to health combining medical expertise with chronic care coordinators who ensure patients needs are met across the continuum of care. From reducing avoidable hospitalizations to empowering patients and families with tools for self-management our mission is to improve outcomes while treating every patient with dignity and respect.
What Youll Be Doing
The Chronic Care Management (CCM) Coordinator plays a key role in supporting patients with complex medical needs. Working under the supervision of the CCM Manager you will work directly with patients providers and care teams to ensure coordinated patient-centered care. This role emphasizes patient engagement care planning and ongoing follow-up to prevent unnecessary hospitalizations and promote better health outcomes.
Tasks
- Deliver chronic care management services to patients with complex or high-risk conditions.
- Conduct assessments of medical educational and psychosocial needs using standardized tools (e.g. depression functional and risk assessments).
- Collaborate with providers specialists and families to support development and updates of individualized care plans.
- Help identify and prioritize patients for medical services each day including prepping any charts to enable efficient and effective provider visits.
- Provide patient and family education focusing on self-management and capacity for self-care.
- Coordinate care transitions including timely post-hospital follow-up medication reconciliation and education on discharge instructions.
- Document all care management activities accurately and in a timely manner.
- Participate in process improvement activities and quality initiatives.
Requirements
Skills & Abilities
- Strong clinical knowledge of chronic disease management.
- Excellent communication skills (verbal written and listening).
- Ability to engage with patients and families in a supportive empathetic and culturally competent manner.
- Strong organizational skills and attention to detail.
- Ability to work independently while collaborating with providers and team members.
- Problem-solving skills with a focus on patient-centered outcomes.
Qualifications
- Licensed Practical Nurse (LPN) or Medical Assistant (MA) preferred.
- Minimum 12 years of experience in chronic care management primary care ambulatory care skilled nursing or hospital settings.
- Knowledge of chronic conditions evidence-based guidelines prevention and patient education.
- Experience with care management documentation and EHR systems preferred.
- Associates degree or higher in a clinical or health-related field preferred.
- Experience with quality improvement or care coordination a plus.
Benefits
- Medical Vision and Dental Insurance
- 401(k) Plan after first year of employment
- Paid Vacation Paid Sick Time and 10 Paid Holidays
- Set schedule no weekends
- Family-friendly work environment
As part of Fortis Care youll join a collaborative mission-driven team that values independence ownership and doing the right thing for patients and partners. We invest in our people celebrate hard work and provide opportunities to grow alongside a company that is redefining post-acute care.
Key Skills
- Senior Care
- Hoyer Lift
- Medical office experience
- Dementia Care
- Home Care
- Nursing
- Alzheimers Care
- Administrative Experience
- Meal Preparation
- Medication Administration
- Memory Care
- Tube Feeding
