Chronic Care Coordinator

PMG Primary Care

8:00am-4:30pm; Full Time

Standard Hours/Week:


General Description:
Working under the direct supervision of the Director of Care Transitions, the Chronic Care Coordinator, in partnership with PMG Primary Care Providers, will collaborate with colleagues to actively engage chronically ill patients in their care; communicate with patients in person, in groups, by telephone and via electronic means. The Chronic Care Coordinator will provide patient education on chronic disease management using Parrish Healthcare methodologies (e.g., Chronic Care Action Plans, Remote Patient Monitoring program, SMART Goals, etc.). The Chronic Care Coordinator will communicate plan of care and all applicable information with the care team, as well as all other applicable and appropriate Care Partners participating in the patient's care. The Chronic Care Coordinator will assist with the coordination of care across the care continuum (including home care, outpatient care, ED care, hospital care, etc.) while maintaining strict patient confidentiality at all times. This position will exemplify the Parrish Healthcare Culture of Choice® philosophies

Key Responsibilities:
  • All activities are documented in the electronic health record of each patient. Communication is maintained with the patient's physician and care team regarding any changes or concerns with the patient that requires additional intervention, consultation, or review.
  • Reports all daily activities, scheduling, and issues with the remote patient monitoring (RPM) devices or vendor.
  • Works in close coordination with Care Partner responsible for the management of the inventory and equipment.
  • Consistently sets "Timer" during all communication to validate billing.
  • Establishes relationship with the Parrish Medical Group care team and the remote patient monitoring company to onboard patients and ensure device activation within first week of receiving a device.
  • Ensures all devices are delivered and instruct patients on setting up the devices.
  • Consistently communicates with the patients care team to ensure parameters are set prior to the utilization of the device.
  • Communicates when a patient breach established reading parameters with urgency and provides appropriate direction based on severity of episode.
  • Manages identified, enrolled, and maintained caseloads of all patients in the program.
  • Effectively uses motivational interviewing techniques and skills to support patient participation in their individualized care plan.
  • Reinforces education provided by patient's medical providers related to the management of the chronic disease or conditions specified in their care plan; helps educate patients about conditions and self-care/condition management using prescribed Action Plans.
  • Prepares detailed, accurate and timely case notes and utilizes care management platform as required to note patient progress and updates.
  • Provides information and assistance through advocacy and education to patient/family on availability and eligibility of entitlements and community-based services. Assists with client navigation of health system.
  • Works collaboratively with care team to provide outreach for and engage resistant/hard to reach clients with overdue screenings or upcoming appointments and /or who have been non-compliant with necessary treatment appointments.
  • Maintains skills, knowledge, and competencies.
  • Performs similar or related duties as assigned.
  • Knows fire, disaster and safety procedures and regulations as it pertains to the work area


Formal Education:
  • Vocational or other Technical School, certification or apprenticeship beyond High School is required.

Work Experience:
  • 2 to 3 years as a medical assistant or related field

Required Licenses, Certifications, Registrations:
  • Medical Assistant certification or Certified Nursing Assistant certification is required.
  • Certification of Health Coach required within 1 year of hire.

Parrish Healthcare is a caring community of healthcare professionals passionate about excellence and fulfilling our mission of providing Healing Experiences For Everyone All The Time®.

Parrish Healthcare has a Culture of Choice®. This means a we have a healing work environment that empowers people to aspire to be their very best. We partner passionate, talented and skilled people in the right role with the right resources. We provide a clear and strategic direction to achieve superior results on behalf of the communities we serve.