Care Coordinator

The Care Coordination Specialist plays a vital role in supporting patients enrolled in Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and Principal Care Management (PCM) programs across the U.S. This position involves coordinating patient care from eligibility verification and enrollment through continuous follow-up. The specialist collaborates closely with patients, physicians, and nursing staff to ensure care plans remain up to date, address any concerns, and accurately document all actions and communications in the patient’s health record.

Key Responsibilities

- Patient Enrollment and Consent: Verify patient eligibility for the relevant care program, obtain or confirm required consents, and document enrollment details within the electronic health record (EHR).

- Chronic and Principal Care Management: Maintain and update patient care plans, schedule outreach activities, and follow up on agreed-upon actions with the care team. For PCM patients, specifically track follow-up related to the condition outlined in the provider’s care plan.

- Remote Patient Monitoring: Monitor incoming patient readings, reach out to patients when expected data is missing, and escalate abnormal readings to the designated clinician following provider protocols. Document all outreach efforts and instructions given.

- Provider and Referral Coordination: Communicate patient concerns and follow-up needs to physicians, nurses, and other healthcare providers. Track referrals and pending actions until outcomes or next steps are recorded.

- Patient Records and Privacy: Accurately record patient contacts, care plan updates, provider communications, and follow-up outcomes in the EHR/EMR or care management system. Adhere to all consent, privacy, and program documentation requirements.

- CCM Billing Support: Maintain thorough documentation to support billing reviews. Differentiate between standard and complex CCM billing and identify the associated common procedure codes.

Required Qualifications

- Practical experience in CCM patient care coordination, program documentation, billing support, or a combination of these areas.

- Working knowledge of patient eligibility verification, consent processes, enrollment procedures, care plan maintenance, and follow-up protocols.

- Proficiency in using EHR/EMR or care management platforms to document patient interactions and manage outstanding tasks.

- Strong verbal and written communication skills for effective patient outreach and direct coordination with healthcare providers.

Preferred Qualifications

- Direct experience with Remote Patient Monitoring, including managing follow-up on missing readings and coordinating with providers regarding abnormal results.

- Experience supporting Principal Care Management patients and tracking condition-specific follow-up activities.

- Familiarity with both CCM operational workflows and billing documentation requirements.

Application Guidance

Candidates are encouraged to specify the duration of their experience within each program, list the systems they have utilized, and provide a brief description of a de-identified patient workflow from enrollment through follow-up. This description should highlight the specific tasks they personally managed throughout the process.