Chronic Care Coordinator

**We are growing! We are expanding our Chronic Care Management team and seeking two new Chronic Care Coordinators.** At PanCare of Florida, our mission is to bring quality healthcare to underserved communities. We believe that compassionate, dedicated healthcare professionals are essential to fulfilling this promise. Are you a dedicated and detail-oriented Chronic Care Coordinator looking to make a meaningful impact on patient care? In this role, you will be at the forefront of ensuring the safe and effective use of medications, working closely with healthcare professionals and patients to optimize treatment outcomes. If you have a passion for patient safety, a keen eye for detail, and thrive in a fast-paced environment, we invite you to apply and become a vital part of our mission to provide exceptional healthcare services. The Chronic Care Coordinator supports patient-centered, team-based care by coordinating services across the continuum of care, addressing barriers to care, and connecting patients with medical, behavioral, and community resources. They work closely with providers, care manager, and interdisciplinary team members to improve patient outcomes, reduce avoidable utilization, and support quality initiatives including HEDIS, UDS, value-based care, Chronic Care Management (CCM), Advanced Primary Care Management (APCM) and Remote Patient Monitoring (RPM). The Care Coordinator is responsible for enrolling, engaging, and managing patients across the practices Advanced Primary Care Management (APCM), Chronic Care Management (CCM), and Remote Patient Monitoring (RPM) programs. This role serves as the primary point of contact for patients between office visits, ensuring care plans are followed, chronic conditions are monitored, device data is reviewed, and all clinical and administrative activity is documented in compliance with CMS billing requirements. **Responsibilities:** - Conduct patient outreach and engagement activities for assigned patient populations. - Assist patients in navigating healthcare services and overcoming barriers to care. - Coordinate care transitions following hospitalizations, emergency department visits, and specialty care encounters. - Facilitate communication among primary care providers, specialists, behavioral health providers, and community partners. - Monitor patient adherence to treatment plans and follow-up recommendations. - Assist patients with appointment scheduling and transportation arrangements as needed. - Participate in development and implementation of individualized care plans. - Assist with risk stratification and identification of patients requiring care management services. - Support enrollment and ongoing management of patients participating in CCM, APCM and RPM programs. - Monitor patients with chronic conditions and provide education on disease self-management. - Document care coordination activities in the electronic health record and care management platforms. - Collaborate with referral staff to address barriers preventing patients from receiving recommended services. - Screen patients for social needs, including food insecurity, housing instability, transportation needs, financial barriers, and utility assistance needs. - Connect patients to community resources and social service agencies. - Advocate for patients experiencing barriers that negatively impact health outcomes. - Support initiatives designed to improve HEDIS, UDS, and value-based performance measures. - Participate in outreach campaigns for preventive screenings and chronic disease management. - Assist with annual wellness visits and care gap closure activities. - Prepare reports and track performance metrics as assigned. - Document all patient interactions accurately and timely in the electronic health record. - Maintain patient confidentiality in accordance with HIPAA and organizational policies. - Complete required reports, registries, and care management documentation within established timelines. -…