Chronic Care Coordinator

1 month ago


Brooklyn, New York, United States Vitability Health Full time
Job Title: Chronic Care Manager

Vitability Health is revolutionizing the way patients receive quality care.

Key Responsibilities:
  • Manage a caseload of patients with chronic conditions, including those with mental health issues.
  • Collaborate with healthcare providers to identify patients who would benefit from care management.
  • Develop relationships with patients and their families to ensure comprehensive care.
  • Provide follow-up support to patients to ensure adherence to their care plans.
  • Respond to urgent and emergency calls during working hours.
  • Anticipate patient needs and ensure necessary documentation and pre-visit planning is completed.
  • Empower patients to manage their health and independence.
  • Determine and coordinate referrals as needed.
  • Work with patients and their care teams to develop individualized treatment plans.
  • Monitor patient progress and report to healthcare providers.
  • Assist patients in setting SMART goals and teaching self-management skills.
  • Identify barriers to treatment and develop strategies to overcome them.
  • Participate in team meetings and peer review activities.
  • Promote collaborative teamwork and work effectively in a team environment.
  • Collaborate with payer case managers to secure additional services.
  • Maintain a list of medical supplies and community resources available to patients.
  • Make recommendations for policies and procedures to ensure timely preventive services.
  • Provide follow-up support during transitions of care.
  • Coordinate disease registry activities.
  • Conduct home visits with physicians to assess patient safety and medication compliance.
Qualification Requirements:

To succeed in this role, the individual must possess the following knowledge, skills, and abilities:

  • Knowledge of the Patient-Centered Medical Home model and insurance industry practices.
  • Understanding of chronic disease and preventive care measures.
  • Bachelor's degree in healthcare administration, health informatics, or a related field.
  • Licensure as a Licensed Practical Nurse or Registered Nurse.
  • Experience working with patients with mental health issues is preferred.


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