Chronic Care Management Coordinator

OUR VALUE PROPOSITION

To provide whole person care that will ensure that all patients have access to primary, specialty and social health care to achieve and maintain optimal wellness at a transparent and affordable cost. The Harmony Healthcare Long Island is a non-profit healthcare organization with 7 health centers, providing primary care and preventative medicine in the following locations in Nassau County: Roosevelt, Elmont, Hempstead, Freeport, Oceanside, and New Cassel/Westbury. In addition, the Harmony Healthcare Long Island has 4 school-based health centers, WIC offices (Special Supplemental Nutrition Program for Women, Infants, and Children) in 3 locations, and a Health Home Care Coordination program. As federally qualified health centers, we serve the individuals in our communities, providing enhanced services, expanded hours and reduced prescription pricing, while raising the level of care. We treat patients regardless of income, residency or immigration status.

The Harmony Healthcare Long Island offers a stable employment opportunity with a growing company, and competitive base compensation along with health and dental insurance, paid time off, 401-K with company match, paid holidays, employee discounts and much more.

OUR VISION

To continue as an eminent healthcare provider on Long Island, dedicating ourselves to providing exceptional health care for all our patients and to transform both the lives of the individual, and the community, for the better, one person at a time.

OUR MISSION

To provide access to equitable, optimal healthcare by improving the overall wellness of all individuals in our communities and delivering high quality comprehensive patient centered care.

JOB TITLE: Chronic Care Management Coordinator

REPORTS TO: Assistant Director of Care Coordination

The following statements reflect the general duties, responsibilities, and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of this position.

POSITION SUMMARY:

The Chronic Care Management (CCM) Coordinator will join the Care Coordination Department with the goal of supporting Medicare patients who are diagnosed with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges, and are at risk for Emergency Department (ED) or inpatient admission or worsening of conditions. The CCM Coordinator would develop partnerships and trust with patients, facilitate communication between patients and Care Team members, coordinate non-face-to-face care services and address Social Determinants of Health (SDOH) to reduce hospitalizations and improve daily functioning. This role ensures that CCM services are consistently provided, appropriately documented, and aligned with regulatory and organizational standards.

RESPONSIBILITIES:

• Patient Engagement & Outreach

• Identify eligible patients, introduce CCM services, and enroll in CCM program by obtaining consent.

• Conduct and maintain monthly outreach to CCM-enrolled patients.

• Perform follow-up calls related to chronic condition management.

• Identify and escalate barriers to care (appointments, medications, social needs).

• Care Coordination

• Coordinate care across providers, specialists and community resources.

• Track referrals, lab results, and follow-up needs.

• Support transitions of care activities by following up with patients discharged within 48-business hours of notification and assisting with scheduling post-discharge care.

• Focus on closing Gaps in Care (GIC).

• Participate in monthly Health Impact Team (HIT) and Multidisciplinary Team (MDT) meetings.

• Manage patient status and monitor progress towards health goals.

• Provide support for patient self-management activities and assess barriers to treatment or adherence.

• Documentation & Time Tracking

• Document CCM activities in the electronic health record (EHR).

• Track accurate time spent on qualifying CCM services.

• Ensure documentation supports billing requirements.

• Care Plan Support

• Assist with development of Care Plan by providing patient reported information.

• Reinforce Care Plan goals with patients.

• Review Care Plan and identify when updates are needed and notify providers.

• CCM Workflow & Program Support

• Review CCM patient rosters regularly.

• Identify and support patients nearing the 20-minute billing threshold.

• Support implementation of CCM workflows at the site level.

• Collaborate with Care Teams and Site Champions.

• Assist with CCM training and meetings as needed.

• Quality & Compliance

• Ensure CCM services align with regulatory requirements.

• Participate in audits and quality improvement activities.

• Maintain HIPAA compliance.

• May be assigned other tasks and duties reasonably related to job responsibilities.

COMPETENCIES

• Possesses strong assessment, critical thinking, and problem-solving skills within the scope of role.
• Manages multiple patients and prioritizes tasks effectively.
• Executes follow-up timely and has strong organizational skills.
• Demonstrates strong interpersonal skills including effective oral, written, and telephonic communication with patients and Care Teams.
• Explains Care Plans and reinforces instructions clearly.
• Manages time efficiently and complete CCM activities consistently and timely.
• Demonstrates initiative in identifying and completing patient outreach.
• Collaborates with colleagues consistently and is able to work as part of a team.
• Presents as goal-oriented and accountable.
• Documents activities and tracks time accurately.
• Follows structured workflows and compliance requirements.
• Identifies barriers to care and escalates appropriately.
• Works effectively with providers, nurses and Care Team members as well as specialists, hospitals and community resources/agencies.
• Supports and demonstrates team-based care models within the Health Centers and within the Department.
• Demonstrates competency in various software applications.
• Possesses strong data analytic skills and interest in tying data to clinical outcomes.
• Adjusts to workflow changes and program needs.
• Maintains openness to feedback and continuous improvement.
• Actively participates in departmental and organizational committees and meetings as applicable.

QUALIFICATIONS:

• High School Diploma or equivalent experience required.
• Bachelor's degree in health-related field, Certified Medical Assistant (CMA), Certified Professional in Healthcare Quality (CPHQ) or similar certifications preferred.
• Two or more years experience in healthcare or case management preferred.
• Experience working with patients with chronic conditions preferred.
• Working knowledge of computer software and electronic health records.
• Basic computer skills (Microsoft Office, data entry).
• Understanding of chronic disease management concepts preferred.
• Familiarity with care coordination or population health workflows preferred.
• Bilingual Spanish or Creole required.

SALARY: Commensurate with experience

MORE INFORMATION: This is a non-exempt position.

HHLI provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, gender, marital status, sexual preference and orientation, or non-disqualifying physical or mental handicap/disability in each aspect of the human resources function. Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The HHLI shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.