Care Coordinator
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Job Location:
Birmingham, MI - USA
Monthly Salary:
Not Disclosed
Posted on:
20 hours ago
Vacancies:
1 Vacancy
Job Summary
The Chronic Care Coordinator supports patients enrolled in CMS Chronic Care Management (CCM) programs by delivering nonface-to-face care coordination services in accordance with Medicare guidelines. This remote role focuses on managing patients with two or more chronic conditions through ongoing monitoring care plan management patient education and care team collaboration to improve outcomes and reduce avoidable utilization.
Key Responsibilities
Provide CMS-compliant Chronic Care Management (CCM) services for eligible Medicare patients with two or more chronic conditions expected to last at least 12 months.
Conduct nonface-to-face patient outreach via phone secure messaging and telehealth platforms to meet monthly CCM time requirements.
Develop document and maintain comprehensive electronic care plans addressing medical functional psychosocial and preventive care needs.
Perform monthly care coordination activities including medication reconciliation support appointment coordination and follow-up on care gaps.
Educate patients and caregivers on chronic disease management medication adherence lifestyle modifications and self-management strategies.
Identify and address barriers to care including social determinants of health and connect patients with community and clinical resources.
Coordinate communication between patients primary care providers specialists pharmacies and other care team members.
Accurately track document and report billable CCM time in compliance with CMS guidelines and organizational policies.
Ensure patient consent for CCM services is obtained documented and maintained per CMS requirements.
Support quality measures risk stratification efforts and care gap closure initiatives.
Maintain strict compliance with HIPAA CMS regulations and internal compliance standards.
Qualifications
HS Diploma or equivalent required.
Demonstrated background in medical knowledge through relevant healthcare experience such as:
o Chronic Care Management (CCM) care coordination or case management roles
o Medical assistant patient navigator health coach EMT CNA LPN or similar healthcare positions
o Healthcare documentation EHR management or clinical support experience
13 years of experience in healthcare population health or chronic care support preferred.
Familiarity with CMS CCM guidelines billing concepts and documentation standards strongly preferred.
Experience working with Medicare populations and chronic disease management preferred.
Prior remote healthcare or telehealth experience is a plus.
Required Skills & Competencies
Strong understanding of chronic disease states medical terminology and care coordination workflows.
Knowledge of CMS CCM requirements including care plans patient consent and time tracking.
Excellent verbal and written communication skills for remote patient engagement.
High attention to detail and strong documentation skills to support compliance and billing accuracy.
Ability to manage a remote caseload and meet monthly CCM time thresholds.
Proficiency with EHR systems care management platforms and telehealth tools.
Ability to work independently while collaborating with clinical and administrative teams.
Patient-centered empathetic approach with strong problem-solving skills.
Reliable high-speed internet and a private secure workspace.
Work Environment
Fully remote work-from-home position.
Requires frequent phone messaging and computer use throughout the workday.
Physical Requirements
Ability to sit and work at a computer for extended periods.
Ability to manage sensitive patient information and emotionally complex patient interactions
Required Experience:
IC
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
