Care Coordinator (Lpn/ Lvn/ Medical Assistant)

We are seeking an experienced Medical Assistant, CNA and Licensed Practical Nurse to join our team! A Care Coordinator working remotely from home - to be working with Medicare patients with multiple chronic conditions

​Qualifications:

• Must have 1+ years experience to be considered as an LPN/ LVN, Medical Assistant or Certified Nursing Assistant working with Medicare patients with multiple chronic conditions
• Multi-tasking is required as the Care Coordinator will need to be able to navigate the platform of their EHR, the internet, Microsoft Office (Excel, Word )
• Email as well as document their time spent with each patient and manage and monitor that each patient under your management receives the required time and scope of service to meet the Chronic Care Management billing requirements.
• A positive attitude, comfortable talking on the phone, be a self-starter, and willing to receive instruction and guidance from the supervisor
• Job duties may be expanded as needs arise. Care Coordinator further agrees to render and provide said work, services, labor, and/or materials in accordance with the specifications in a workmanlike manner. All services are to be consistent with applicable Medicare regulations for billing CCM services

​Responsibilities:

• Assist Physicians/Practitioners who treat Medicare patients with chronic conditions.
• Each chronic care patient must receive a minimum of 20 minutes or more spent on their case each month based on the time needed to fulfill the scope of the billing code for all of their chronic conditions.
• This time includes wellness checks by phone, education on their conditions, care coordination, assistance with appointments, prescription refills, and referrals, etc.….
• The Care Coordinator will be responsible to manage a caseload of 12 to 14 patients on a daily basis. This job is telephonic and employees work at their designated home office.
• The Care Coordinator must have excellent phone skills, be comfortable calling patients to discuss care, make appointments, and provide education without direct supervision.
• Care Coordinators must have superior time management and communication skills, show initiative, and be self-motivated.
• A positive attitude, comfortable talking on the phone, be self-starter, and willing to receive instruction and guidance from supervisor
• Follow Up on a monthly basis with the patient by reviewing the patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues).
• Provide CCM patients with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management.
• Contact patients with gaps in preventive health care services and assist them in schedule required screening or diagnostic tests with their providers.
• Review patient’s current medication profile; conduct medication with a review of adherence and potential interactions, and address with the patient and providers as necessary.
• Additionally, as the Care Coordinator, you will oversee the patient’s self-management of medications.
• Successfully engage patients by reviewing their care plan monthly that promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions. Coordinates the care plan with patients, caregivers, PCP, specialists, community resources, behavioral health contractors, and other health plan and system departments as appropriate.
• Document all activities in the EHR and time elements in a report to be submitted daily following CareVitality's standards and identify trends and opportunities for improvement based on information obtained from interaction with patients, providers and technology solutions utilized.
• Health Risk Assessments or the non-face-to-face portion of annual wellness visits may be added in the future as well.
• If at any time the patient needs a reassessment the Care Coordinator would need to immediately escalate this patient to the Care Manager that is assigned to the practice.

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