Bilingual Chronic Care Coordinator

Bilingual Chronic Care Coordinator

• Identify patients who are eligible for Chronic Care Management (CCM) through contact with providers and/or clinical staff.

• Coordinate and facilitate patient care through assessment, evaluation, planning, and implementation.

• Contact eligible patients to educate about the CCM program and to obtain consent to participate and to create an annual patient centered care plan in collaboration with provider based on the patient/provider goals identified for their chronic conditions.

• Monitor for timely renewal of yearly care plans.

• Serve as a liaison between patient/provider/and medical staff to establish or update a care plan or to coordinate referrals or address patient health care needs.

• Perform timely follow up calls to assess patient’s current medical, functional and psychosocial needs. This will include assessment of health conditions, initiate medication reconciliation, patient goal setting, education, coordinating referrals with providers, pharmacy, and/or other health care providers.

• Provide patient with ongoing education and outreach to support patient’s achievement of self-management.

• Coordinate through collaboration with providers/medical staff to ensure all of the patient’s preventive health opportunities are addressed in a timely manner.

• Assist the patient when transitioning from an inpatient facility by assessing transitional needs, performing medication reconciliation, evaluating availability of support/assistance for patient, coordinate appointment with PCP for patient within 7 calendar days from discharge, coordinate transportation, DME, specialist appointments etc. Collaborate with provider when establishing or updating a care plan.

• Prepare timely, detailed and accurate reports.

• The overall goal is to improve clinical outcomes, increase patient satisfaction and promote cost effectiveness.

• Perform other related duties as assigned.

Education/Qualifications

• Licensed Vocational Nurse or Licensed Practical Nurse certification and/or diploma required

• GED or High School Diploma

• Minimum 2 years’ experience in a clinical setting, physician’s office, or case management position.

• Bilingual (Spanish) a plus

• Excellent computer skills with knowledge of EMR. eCW a plus.

• Excellent written and communication skills.

• Detail oriented, analytical, organized, self-motivated, high energy, and have the ability to prioritize, multi-task and meet deadlines in a fast-paced environment.

• Treat patients and co-workers with respect, kindness, care, empathy, compassion, patience and an optimistic outlook.

License/Certification:

• Certified Medical Assistant (Required)
• LVN (Preferred)
• LPN (Preferred)

Candidates will have:

· Drug test

· Typing test

· Verifiable experience check

· Background check

· Computer knowledge test

· Commitment on schedule

· English/Spanish Test (if applicable)

· Work Authorization