Chronic Care Coordinator

3 days ago

Brooklyn, New York, United States Vitability Health Full time
Job Summary

Vitability Health is revolutionizing the way patients receive quality care. We are seeking a skilled Chronic Care Manager to join our team.

Key Responsibilities
  • Manage a caseload of patients with chronic conditions, including those with mental health issues.
  • Collaborate with physicians, providers, and practice staff to identify patients for care management.
  • Develop relationships with patients as an integral member of the team.
  • Provide follow-up management to ensure patient compliance with individual care plans.
  • Maintain availability for telephone advice and handle urgent/emergency calls during working hours.
  • Anticipate patient needs, ensuring necessary documentation and pre-visit planning is completed or requested.
  • Promote patient self-management and empower patients/families to achieve maximum wellness and independence.
  • Determine and coordinate referrals as needed.
  • Work with patients and care teams to coordinate change readiness, needs assessment, and individualized treatment care plans.
  • Maintain accessible, consistent documentation of patient self-management measures and reporting progress toward goals.
  • Assist patients in setting SMART goals for self-management, teaching them how to perform self-management tasks, and reporting abnormal findings to the physician team.
  • Assess barriers when patients have not met treatment goals, are not following treatment plans, or have missed important appointments.
  • Participate in regular team meetings and peer review activities.
  • Promote collaborative teamwork and work effectively with peers in a team situation.
  • Collaborate with payer Case Managers for additional services when appropriate.
  • Maintain a list of medical supplies and community resources available to patients and maintain collegial relationships with frequently used entities.
  • Make recommendations for policies/procedures to ensure timely preventive services for all who qualify.
  • Provide follow-up in transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).
  • Coordinate disease registry activities.
  • May conduct home visits with a physician to assess safety, medication compliance, and home environment.
  • Participate in departmental and organizational committees as applicable.

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