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Full TimeDays

Job Summary: The Patient Chronic Care Program Coordinator is responsible for coordinating and managing care for patients with multiple chronic conditions. This role supports improved patient outcomes through care planning, patient education, care transitions, medication management, and ongoing communication with patients, providers, caregivers, and community resources. The coordinator helps ensure compliance with Medicare Chronic Care Management requirements and promotes quality, patient-centered care.

Minimum Education: High school diploma or GED.

Licensure, Registration and/or Certification: None.

Work Experience: Minimum 3 years in medical related field.

Knowledge, Skills and Abilities: Knowledge of chronic disease processes, treatment plans, and evidence-based care management practices along with Medicare Chronic Care Management, Principal Care Management, Transitional Care. Excellent communication skills, both written and verbal that present clear and concise information. Strong patient assessment and care planning skills. Skilled in care coordination, case management, and follow-up activities. Ability to educate and motivate patients toward self-management of chronic conditions. Ability to maintain confidentiality and exercise discretion when handling sensitive patient information. Ability to recognize changes in patient status and appropriately escalate concerns to providers and coordinate multiple aspects of patient care across healthcare settings and adapt to changing healthcare regulations, organizational priorities, and patient needs. Ability to work independently and collaboratively in a fast-paced environment, managing multiple priorities with competing deadlines.

Essential Functions and Responsibilities: Identifies and enrolls eligible patients in Chronic Care Management programs. Develops, implements, and updates comprehensive patient-centered care plans. Conducts monthly patient outreach and documents non-face-to-face care management services. Monitors patient progress toward health goals and address barriers to care. Coordinates referrals, diagnostic testing, specialist appointments, and community services. Assists patients with medication adherence and understanding treatment plans. Educates patients and families regarding chronic disease management, preventive care, and healthy lifestyle choices. Facilitates communication between patients, providers, specialist and hospital. Supports care transitions following emergency department visits, hospitalizations, or skilled nursing facility stays. Maintains accurate documentation in the electronic health record. Monitors quality metrics and participate in quality improvement initiatives. Ensures compliance with Centers for Medicare and Medicaid Services, Medicare, Rural Health Clinic, Health Insurance Portability and Accountability Act, and organizational policies.

Decision Making: The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from a supervisor.

Working Relationships: Coordinates activities of others (does not supervise). Works directly with patients and/or customers. Works with internal and/or external customers via telephone or face to face interaction. Works with other healthcare professionals and staff.

Special Job Dimensions: None.

Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

Monkey Island Clinic - Vinita Campus

Location:

Afton, Oklahoma 74331Under the Oklahoma Medical Marijuana Use and Patient Protection Act (OMMA), a safety sensitive position is defined as any job that includes tasks or duties that the employer believes could affect the safety and health of the employee performing the task or others. This position has been identified as a safety sensitive position. This statute allows employers to lawfully refuse to hire applicants for safety-sensitive jobs or to discipline or discharge employees who work in safety-sensitive jobs if they test positive for marijuana, even if they have a valid license to use medical marijuana.