Chronic Care Coordinator – SNF

Who We Are:

Vis-À-Vis Health is a comprehensive care solution, providing physician services in the community as well as in Skilled Nursing Facilities.

Vis-À-Vis Health provides convenient access to high-quality medical care to patients within the house call setting in a compassionate, complete, comprehensive, and cost-effective manner. We are focused on creating a revolutionary patient-centric healthcare model that leverages technology to generate positive healthcare outcomes and savings with the help of our medical teams.

Job Description:

We are seeking a CCM (Chronic Care Management) Coordinator to support and enhance our Chronic Care Management program. The CCM Coordinator will be responsible for coordinating care services for patients with chronic conditions, ensuring they receive ongoing support, follow-up, and education to improve health outcomes. This role involves working closely with providers, patients, and interdisciplinary teams to implement care plans, track patient progress, and optimize care delivery. The ideal candidate will have a strong background in healthcare coordination, patient engagement, and chronic disease management.

Duties/Responsibilities:

• Coordinate care for patients enrolled in the Chronic Care Management (CCM) program.

• Conduct patient outreach to review care plans, address concerns, and provide education on managing chronic conditions.

• Collaborate with physicians, nurse practitioners, and other healthcare professionals to implement and adjust individualized care plans.

• Document patient interactions, care coordination activities, and health status updates in the electronic health record (EHR).

• Monitor patient compliance with treatment regimens, medications, and lifestyle changes.

• Assist in scheduling follow-up appointments, diagnostic tests, and specialist referrals as needed.

• Ensure compliance with CMS guidelines for Chronic Care Management services.

• Serve as a patient advocate, providing support and resources to improve health outcomes.

• Track and report key metrics related to patient engagement, program effectiveness, and care coordination.

Required Skills/Abilities:

• Strong understanding of Chronic Care Management and care coordination principles.

• Excellent communication and interpersonal skills to engage patients and healthcare providers.

• Ability to work independently while collaborating with an interdisciplinary team.

• Proficiency in electronic health records (EHR) and healthcare documentation.

• Knowledge of Medicare guidelines and reimbursement policies for CCM services.

• Strong organizational skills with the ability to multitask in a fast-paced environment.

Required Skills/Abilities:

• Associate’s or Bachelor’s degree in Nursing, Healthcare Administration, Social Work, or a related field (preferred).

• Experience in care coordination, case management, or chronic disease management.

• Prior experience working in a healthcare setting, such as a physician office, hospital, or long-term care facility.

Benefits (Full-time Providers)

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance
• Unlimited Paid time off

This position is compensated on a per-code basis.

• CPT Code 99490: $10.00 per completed code

• CPT Code 99439: $6.00 per completed code

Work Location:

Remote

Employment Status: Full-Time

Pay Grade: W2

FLSA Status: Non-Exempt

Vis-À-Vis Health recognizes and values the key to success is the experiences and perspectives of people from all walks of life. Vis-À-Vis Health is proud to be an equal employment opportunity employer to all individual, regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law.

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