Clinical Care Coordinator RPM

The Clinical Care Coordinator (CCC) works in collaboration with the primary care provider and all other members of the care team to support chronic disease care management for high-risk, high-need patients in a manner that is medically appropriate and cost effective.

Requirements

• Conduct primarily telephonic communication with patients to support the provider in addressing patients’ medical and social needs.
• Occasionally patients in their homes to support proactive and efficient care delivery.
• Serve as the contact, advocate, and informational resource for patients, care team, family/caregiver(s) and community resources.
• Facilitate patient access to appropriate medical and specialty providers.
• Educate and refer patients to community resources.
• Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients to promote adherence to provider recommendations and instructions.
• Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
• Address medication adherence.
• Complete daily tasks such as taking clinical notes, reviewing medical records, following up on care gaps, coordinating chronic disease care, and other duties as assigned.
• Provide education to patients, families/caregivers regarding resources for health care management, and condition exacerbations.
• Communicate changes in patient’s status timely with the care team.
• Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.