Veterans Wanted!
Cabin Creek Health Systems
  • Full Time
  • Immediately
  • $14.00 plus Hour
  • 4602 MacCorkle Ave SE, Charleston, WV 25304
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Come Join Our Veteran Team in Kanawha City!

Care Coordinator

Job Title:  Care Coordinator 


Minimum Salary: $14.00


Position Class: Non-Exempt


Supervision Received:  Director of Clinical Quality  


Supervision Exercised: None


General Summary: 


The Care Coordinator works in partnership with selected patient populations, including those with chronic conditions or “high-risk”, and their clinical care team to:

  • Promote timely access to appropriate care
  • Increase utilization of preventative care
  • Create and promote adherence to a care plan, developed in coordination with the patient and medical provider
  • Increase patient’s ability for self-management and shared decision making
  • Connect patients to relevant community resources, with the goal of enhancing patient health and well being


Core Duties and Responsibilities, which include the following and other duties as assigned:


  • Schedule and complete the care coordination portion of the Medicare Annual Wellness Visits; goal 30 visits completed per month.
  • Appropriately manage patients who sign up for the Chronic Care Management (CCM) program, e.g. monthly contact.
  • Utilize 3rd party on-line databases to determine patient care gaps and intervene with high utilizing patients.  Follow up with patients who need preventive or chronic disease management services.
  • Develop and manage special patient population registries, this includes following up with patients who are overdue for certain services; e.g. HgA1c tests for diabetics.
  • Assist with the organization and facilitation of medical provider led group visits.
  • Organize at least monthly health education events for patients.
  • Network with members of the community and plan outreach events on a bi-annual basis.
  • Perform a review of the medical record and identify possible gaps, inaccuracies and corrects them.
  • Identify and connect patients with potential benefits or community resources for which the patient may be eligible.
  • Develop care plans for patients who have been assigned to the care coordinator panel or referred by a provider.
  • Utilize the electronic health record to document all significant patient encounters.
  • Provides the patient education concerning their condition and medical situation.
  • Signs patients who qualify up for the WV Wisewoman Program.  Intervenes with patients enrolled in the program as appropriate and timely submits all paperwork.


Education and Experience:

  • Licensed or credentialed medical assistant, practical nurse, or social worker
  • 3 – 5 years of experience in a clinical or community resource setting; care coordination and/or case management experience is desirable
  • Experience with health IT systems, proficient with the use of email and online reporting systems
  • Highly organized with ability to keep accurate notes and records


Physical Demands:

Although most of the workday is spent sitting, the workday may include activities such as standing, walking, reaching, bending and lifting. Requires full range of body motion, including assisting in the lifting of patients manually. The employee may occasionally lift and/or move up to 20 pounds, and occasionally lift and move up to 50 pounds. Eye-hand coordination and finger dexterity.  Requires corrected vision and hearing to normal range. Working with ill patients and their caregivers may be stressful.


Environmental/Working Conditions:

Primary Care Health Center with combination of office and exam room settings.  Frequent exposure to communicable diseases, body fluids, sharp instruments and needles, cleaning chemicals, medicinal preparations.  May require working extended shifts and hours as necessary. 

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