Department :

Physician Services Job Title :

Care Coordinator Status :

Non

• exempt;

Full Time Hours:

M-F, 8a-4:30p

Salary Range:

(CMA): $20.17

• $26.22 (LPN): $25.41
• $33.03 (RN): $29.57
• $44.

35 per hour, based on experience.

Description:

Physician Services is seeking a compassionate and highly organized Care Coordinator to join our dedicated primary care team. In this role, you will collaborate with providers, patients, caregivers, and community partners to coordinate high-quality, patient-centered care that improves health outcomes and enhances the patient experience. Responsibilities include coordinating care plans, connecting patients with appropriate resources, and managing Medicare Annual Wellness Visits (AWVs), Transitional Care Management (TCM), and Chronic Care Management (CCM) services in compliance with CMS guidelines. The Care Coordinator plays a vital role in supporting preventive care initiatives, chronic disease management, and value-based care programs while ensuring seamless transitions of care and continuity for our patients. Salary Range (Based on Licensure and Experience): Certified Medical Assistant (CMA): $20.17

• $26.22 per hour Licensed Practical Nurse (LPN): $25.41
• $33.03 per hour Registered Nurse (RN): $29.57
• $44.

35 per hour

Responsibilities:

Conduct comprehensive patient assessments to identify medical, behavioral, and social needs. Develop, implement, and monitor individualized care plans in collaboration with providers and interdisciplinary care teams. Coordinate referrals, follow-up appointments, diagnostic testing, and specialty care. Serve as the primary point of contact for patients, families, and caregivers regarding care coordination needs. Identify barriers to care and connect patients with appropriate community resources and support services. Educate patients and caregivers on disease management, medications, preventive care, and available healthcare resources Medicare Annual Wellness Visits (AWV) Identify eligible Medicare beneficiaries for Annual Wellness Visits. Schedule and coordinate Medicare Annual Wellness Visits. Complete required health risk assessments, preventive screenings, and documentation in accordance with CMS guidelines. Educate patients on preventive health services and recommended screenings. Collaborate with providers to ensure completion of personalized prevention plans. Transitional Care Management (TCM) Monitor daily hospital and emergency department discharge reports. Contact eligible patients within the required CMS timeframe following hospital discharge. Coordinate follow-up appointments within CMS-required timelines. Reconcile medications and ensure patients understand discharge instructions. Identify potential complications and communicate concerns to providers. Document all TCM services according to CMS billing requirements. Chronic Care Management (CCM) Identify and enroll eligible patients with multiple chronic conditions into the CCM program. Develop and maintain comprehensive care plans. Provide monthly non-face-to-face care coordination services. Conduct routine outreach to monitor patient status, medication adherence, and care plan goals. Coordinate services among providers, specialists, pharmacies, and community resources. Ensure all CCM documentation and time requirements meet CMS guidelines for reimbursement. Maintain ongoing communication with physicians, specialists, hospitals, home health agencies, and other healthcare partners. Document all patient interactions accurately and timely in the electronic health record (EHR).

Qualifications:

Associate's or Bachelor's degree in Nursing, Social Work, Healthcare Administration, Public Health, Human Services, or a related field preferred. Equivalent combination of education and relevant experience may be considered. Experience Two or more years of experience in care coordination, case management, ambulatory care, primary care, or population health preferred. Experience with Medicare Annual Wellness Visits, Transitional Care Management (TCM), Chronic Care Management (CCM), or value-based care programs preferred. Experience working within an electronic health record (EHR) system. Come join our team at Pana Community Hospital!