Chronic Care Coordinator

Job Summary:

We are seeking a dedicated and detail-oriented Chronic Care Specialist to enhance patient outcomes through proactive care coordination, including Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services. The ideal candidate will possess a strong background in healthcare delivery, chronic care management, medical coding, and case management, with hands-on experience supporting patients with chronic conditions through both in-person and remote care models. This role involves coordinating care plans, monitoring patient-reported and device-generated data, ensuring regulatory compliance, and empowering patients to manage their health effectively.

Key Responsibilities:

• Coordinate and monitor ongoing care for patients with chronic conditions, ensuring adherence to individualized care plans across CCM, RPM, and RTM programs.
• Monitor, review, and document RPM and RTM data (e.g., vital signs, therapeutic adherence, symptom tracking) and escalate findings to appropriate clinical staff as needed.
• Utilize CPT coding, ICD-9, and ICD-10 coding systems accurately for CCM, RPM, and RTM documentation and billing purposes.
• Collaborate with healthcare providers, social workers, behavioral health specialists, and care teams to develop comprehensive care coordination, discharge planning, and follow-up strategies.
• Manage medical records meticulously, ensuring HIPAA compliance and patient data confidentiality at all times.
• Conduct patient intake assessments to identify clinical, psychosocial, and technology-readiness needs related to chronic care, RPM, and RTM enrollment.
• Support discharge planning by coordinating post-acute services, RPM enrollment, patient education, and self-management tools.
• Maintain thorough, timely documentation of patient interactions, medical terminology, treatment plans, monitored data, and progress in electronic health records (EHRs).
• Engage patients through phone, digital tools, and monitoring platforms to promote understanding of medical conditions and sustained participation in care programs.

Essential Functions:

• Complete individualized patient-centered care plans and provide management services using CCM software.
• Maintain frequent patient contact to coordinate care, provide support, and ensure program compliance to improve outcomes.
• Communicate emergent needs or life-threatening episodes to Psychiatric Clinicians.
  
• Accurately document all verbal and written client communications in a timely manner.
  
• Manage a caseload of up to 500 members.
  
• Coordinate with schedulers to set and verify all required patient appointments.
  
• Manage referrals and review member medications as necessary.
  
• Qualify members for end-of-month billing and add them to the billing system.
  
• Create and update care plans and review member charts as needed.

Qualifications:

• Prior experience in Chronic Care Management (CCM) with Remote Patient Monitoring (RPM) and/or Remote Therapeutic Monitoring (RTM) is strongly preferred.
• Proven experience working in hospital, acute care, ambulatory, or virtual care settings.
• Strong knowledge of medical coding practices, including CPT, ICD-9, ICD-10, and familiarity with CCM, RPM, and RTM billing requirements.
• Experience with remote monitoring platforms, connected health devices, or therapeutic tracking tools is highly desirable.
• Familiarity with behavioral health integration, social work principles, and pediatrics is an advantage.
• Demonstrated experience in discharge planning, care coordination, intake assessments, and case management.
• Excellent attention to detail in managing documentation, medical records, and compliance requirements.
• Ability to communicate effectively with multidisciplinary teams while maintaining strict HIPAA compliance.
• Background in medical coding, healthcare administration, or population health management is a strong asset.

Preferred Skills:

• • Strong oral, written, and phone communication skills.
    
  • Ability to work independently with excellent organization and time management.
    
  • Knowledge of clinical practices, diagnostic procedures, and treatment protocols.
    
  • Strong clinical judgment and critical thinking skills.
    
  • Ability to build trusting relationships with patients and partner practices in a fast-paced environment.
    
  • Results-oriented with a focus on quality and daily productivity.
    
  • Proven problem-solving, consultative, and customer service skills