Job Description PRIMARY ACTIVITIES/DUTIES: Care Coordinators assist patients with managing their blood pressure by daily monitoring and calls. As a Care Coordinator, you will have an assigned group of patients to follow up with monthly via phone. Conversations include reviewing daily blood pressure readings, educating patients on improving hypertension control, and assisting patients to supporting the plan of care established by their provider. Verify and record the patient’s demographics, medical issues, medications, and risk management factors to create a clinical summary using specialized medical software. Contact patients when blood pressure exceeds established parameters to evaluate the situation. Communicate with practices and/or providers, based on established protocols, when readings exceed established parameters. Help provide the patient with a means to make timely contact with healthcare practitioners in the practice who can address any urgent needs about their hypertension. Responsible for registering chronic care management and principal care management. Complies with documentation requirements of CCM and PCM program by carrying out the care plan with patient, family/caregiver and providers and recording in the EMR. Monitor adherence to care plans, evaluate effectiveness, monitor patients progress in a timely manner and facilitate changes as needed. Provides patient health counseling, education, and instruction. Ability to follow HIPAA guidelines. Handle potentially difficult conversations calmly and professionally. Participate in individual&Group projects as directed by management. Complete audits of Chronic Kidney Disease Patients to ensure patients have appointments scheduled. Other duties, as assigned Qualifications Able to communicate with customers at all levels Must be computer literate with a high comfort level with computers and computer programs MS Word, MS Excel, Email and Internet Candidate must be able to speak on the telephone intermittently throughout the day Candidate must be able to read and write English fluently Candidate must be able to provide and confirm a safe home office environment Home office must be HIPAA compliant Must be able to meet home internet and phone requirements WORK EXPERIENCE: Minimum of 1–3-year work experience in healthcare setting involving patients with complex chronic disease states preferred. Previous call experience with U.S. based clients. Must be PC proficient and able to thrive in a fast-paced setting; experience in Microsoft Office Suite: Outlook, Word and Excel a must. License/Certifications CNA, MA, CMA, RMA, or CCMA (Required) SKILLS Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure and basic medical management of these states. Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management skills. Strong organizational and interpersonal skills Excellent customer service skills demonstrated by positive feedback from patients/team. Ability to identify problems and recommend solutions. Ability to read, write and communicate effectively orally and in writing. Basic computer skills including previous work with an electronic health record (EHR) Language Any other language in addition to English is preferred. Work Schedule Remote Flexible Work weekends and 2nd shift preferred Benefits No benefits offered 1099 position