Chronic Care Coordinator

About the position

Tanner Clinic has an immediate opening for a Chronic Care Coordinator. This position is located at Layton Parkway and is full-time. The role involves reviewing patient data within population health tools and Electronic Health Record (EHR) systems to identify and enroll appropriate high-risk patients in care management services. The coordinator will work in partnership with primary care providers and patients to establish comprehensive, goal-driven care plans, addressing chronic diseases, psychosocial, behavioral health, hospital utilization, pharmaceutical, and social determinants of health barriers. The coordinator will also coordinate care by serving as an advocate and resource for patients, their families, and providers, building effective relationships in the community across the continuum of care. Compliance with billing requirements and documentation of care plans is essential, as well as leveraging ACO methodology to provide telephone-based support to patients. The role includes identifying and dis-enrolling patients when goals are achieved, liaising with ACO field team members, developing and delivering care manager training, and participating in additional ACO activities as required.

Responsibilities

• Review patient data within population health tools and EHR system to identify and enroll appropriate high-risk patients in care management services.
• Work in partnership with primary care providers and each patient to establish a comprehensive goal-driven care plan.
• Apply clinical knowledge to address chronic disease, psychosocial, behavioral health, hospital utilization, pharmaceutical, and social determinants of health barriers.
• Coordinate care by serving as the advocate and resource for the patient, their family, and their providers.
• Comply with billing requirements and document care plans and care management services provided.
• Leverage ACO methodology and care management toolkits to provide telephone-based support to patients.
• Identify and dis-enroll patients when goals have been achieved.
• Liaise with ACO field team members and care management experts to ensure alignment with ACO initiatives.
• Develop and deliver care manager training on population health tools and chronic care management guidelines.
• Aid in the development of new or improved ACO systems, tools, and workflows.
• Perform components of the Medicare Annual Wellness Visit as requested.
• Participate in additional ACO activities within the practice as required.

Requirements

• MA or CNA preferred.
• At least 2-5 years of experience in case management, community public health, utilization management, or care coordination.
• Knowledge of patient activation, motivational interviewing, chronic disease self-management, and goal-driven care planning.
• Excellent computer skills and willingness to learn new software applications.
• Electronic health record experience and population health management tool experience a plus.
• Familiarity with healthcare entities operating within the State.
• Experience providing care to vulnerable populations.
• Understanding of value-based healthcare, the ACO model, and population health fundamentals.
• Exceptional communication skills, both written and oral.
• Strong work ethic built on productivity, collaboration, and teamwork.
• Ability to manage multiple projects and activities with minimal supervision.
• Demonstrated knowledge of continuous quality improvement techniques.

Nice-to-haves

• Experience in training and education on population health tools and chronic care management guidelines.
• Familiarity with ACO methodology and care management toolkits.