Chronic Care Management Coordinator - OVP Health : Job Details

JOB DESCRIPTION: The Chronic Care Management (CCM) Coordinator manages and supports patients with chronic conditions to improve their health, outcomes and quality of life. This role will focus on delivering patient-centered care by developing individualized care plans, coordinating care withhealthcare providers, monitoring patient progress, and ensuring adherence to care management programs. The CCM Coordinator will work closely with patients, their families, and the healthcare team to promote comprehensive, preventative, and cost-effective care.PRINCIPAL DUTIES AND RESPONSIBILITIES:Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Develop, implement, and monitor individualized care plans for patients with chronic conditions, ensuring continuity of care and regular follow-up.
• Document all patient interactions, assessments, and care plans accurately and in a timely manner, in compliance with organizational standards and regulations.
• Provide education on chronic conditions, treatment plans, and preventive health strategies to empower patients and their caregivers.
• Track patient progress and outcomes, monitor engagement in CCM programs, and report metrics to the Practice Manager or Medical Director.
• Work with billing and coding staff to ensure accurate documentation for CCM services to optimize reimbursement.
• Assist patients in accessing appropriate healthcare resources, including specialty care, community resources, and support services.
• Ensure chronic care management activities comply with Medicare guidelines and organizational policies.
• Coordinate with physicians, nurses, social workers, and other healthcare professionals to address patients' clinical and non-clinical needs.
• Serve as the primary point of contact for patients enrolled in chronic care management, providing education on disease management, medication adherence, and lifestyle modifications.

QUALIFICATIONS:

• A bachelor's degree in nursing, social work, or a related healthcare field is preferred; equivalent clinical experience may be considered.
• Minimum of 1 year of experience in chronic care management, case management, or a related field in an outpatient setting.
• RN, LPN, or Medical Assistant certification/licensure preferred, depending on state regulations.

COMPETENCIES:

• Strong communication and interpersonal skills to effectively interact with patients and healthcare teams.
• Knowledge of chronic disease management principles and patient education techniques.
• Proficiency in electronic health records (EHR) and care coordination platforms.
• Strong organizational skills with an ability to manage multiple patients and tasks efficiently.
• Familiarity with Medicare and Medicaid guidelines for chronic care management is a plus.

PHYSICAL DEMANDS:Physical demands described are representative of those that must be routinely met by and employee to successfully perform the essential duties of this position. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essentials duties.

• Ability to lift minimum 25 pounds.
• Ability to perform job responsibilities in a facility with multiple levels and without elevator or mechanical transportation.
• Operates a computer and keyboard.

POSITION TYPE/EXPECTED HOURS OF WORK:This is a full-time position. Monday-Friday, with occasional evenings based on patient needs. WORK ENVIRONMENT:This job operates in an outpatient facility environment. WORKING CONDITIONS:Working conditions described are representative of those that must be routinely met by and employee to successfully perform the essential duties of this position. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform essential duties.

• Smoke-free environment.
• Prolonged periods sitting at a desk and working on a computer, occasional walking and standing, and light physical effort.

This position description is not intended to be a complete list of all responsibilities, duties or a skill required for the job and is subject to review and change in accordance with the needs of OVP Health and contractual obligations.Our MissionCentered in compassion and excellence, we serve to save lives while nurturing stronger and healthier communities for our persons served , employees, and families.CORE VALUES: Moral, Ethical and Behavioral GuidelinesFamily: OVP Health is proud to be a family-owned company. We hold ourselves to the highest standards: the family values that are passed from generation to generation. However, at OVP Health we also believe that our coworkers, our persons served and our community are family. That means we will always treat you like family, no matter what health struggle you're facing. Quality:In an ever-changing health care industry, our commitment to consistent, high-quality care has been the same since day one. Our highly trained physicians and nurses are constantly striving to provide the latest, most advanced care and treatment to persons served . Our medication-assisted treatment program is fully accredited by CARF (Commission on Accreditation of Rehabilitation Facilities). In everything we do, our goal is to provide persons served and their loved ones with the highest level of care possible.Community: At OVP Health, we believe in giving back. And our commitment to improving the communities we serve doesn't stop at providing high-quality medical care. After work and on weekends, OVP Health employees can be found volunteering in the community, and we are proud to support a number of nonprofit groups in the areas we serve. Integrity: Ethical, responsible health care is a nonnegotiable at OVP Health. We treat our coworkers, our persons served and our communities with honesty, truest and respect and hold ourselves to the highest standards of ethics and professionalism. Earning a patient's trust and loyalty is our greatest reward. EEO STATEMENTOVP Health provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, OVP Health complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfers, leaves of absence, compensation and training.OVP Health expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper inference with the ability of OVP Health employees to perform their job duties may result in discipline up to and including discharge.