Bilingual Chronic Care Coordinator (English/Spanish) -

Cardiology Practice Location:

Humble Employment Type:

Full-Time Department:

Primarily cardiovascular Position Summary We are seeking a bilingual, compassionate, organized, and detail-oriented Chronic Care Coordinator to join our growing cardiovascular team. The Chronic Care Coordinator plays a vital role in improving patient outcomes by providing ongoing support, education, and care for patients with chronic cardiovascular conditions. This position serves as a liaison between patients, providers, specialists, and community resources to ensure patients receive comprehensive, high-quality care while meeting Chronic Care Management (CCM) program requirements. This role requires frequent communication with English and Spanish speaking patients. Essential Duties and Responsibilities

• Enroll eligible patients into the Chronic Care Management (CCM) program and obtain required consents under guidance of board certified physician.
• Conduct monthly patient outreach via telephone to assess health status, identify barriers to care, and provide education.
• Develop, update, and maintain individualized care plans.
• Coordinate care between cardiologists, primary care providers, specialists, hospitals, and other healthcare organizations.
• Monitor patient adherence to medications, treatment plans, and follow-up appointments.
• Document all patient interactions accurately and timely within the electronic medical record (EMR).
• Identify patients at risk for hospitalization or worsening chronic conditions and communicate concerns to providers.
• Assist patients in accessing community resources and support services.
• Review hospital admissions, emergency room visits, and transitions of care.
• Collaborate with clinical staff to improve quality metrics and patient outcomes.
• Ensure compliance with Medicare CCM guidelines and practice policies.
• Participate in team meetings and quality improvement initiatives.

Qualifications Required:

• Licensed Practical Nurse (LPN/LVN)
• Bilingual (English/Spanish)
• Minimum of 1 year of healthcare experience in care coordination, chronic care management, case management, or medical office operations.
• Strong communication, organizational, and customer service skills.
• Experience with electronic medical records (EMR).
• Ability to manage multiple priorities in a fast-paced environment.
• Knowledge of HIPAA regulations and patient confidentiality requirements.

Preferred:

• Cardiology experience preferred.
• Experience with Medicare Chronic Care Management programs.
• Knowledge of cardiovascular disease processes, including heart failure, hypertension, coronary artery disease, atrial fibrillation, and cardiomyopathy. Skills and Competencies
• Excellent verbal and written communication
• Strong patient engagement and relationship-building skills
• Attention to detail and accurate documentation
• Time management and multitasking abilities
• Problem-solving and critical thinking
• Ability to work independently and collaboratively Benefits
• Competitive salary
• Medical, dental, and vision insurance
• Paid time off
• Paid holidays
• Retirement plan options
• Supportive team environment

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Paid time off Vision insurance

Work Location:

In person