The posting
Job Summary:
We are seeking a dedicated and detail-oriented Chronic Care Specialist to enhance patient outcomes through proactive care coordination, including Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services. The ideal candidate will possess a strong background in healthcare delivery, chronic care management, medical coding, and case management, with hands-on experience supporting patients with chronic conditions through both in-person and remote care models. This role involves coordinating care plans, monitoring patient-reported and device-generated data, ensuring regulatory compliance, and empowering patients to manage their health effectively.
Key Responsibilities:
- Coordinate and monitor ongoing care for patients with chronic conditions, ensuring adherence to individualized care plans across CCM, RPM, and RTM programs.
- Monitor, review, and document RPM and RTM data (e.g., vital signs, therapeutic adherence, symptom tracking) and escalate findings to appropriate clinical staff as needed.
- Utilize CPT coding, ICD-9, and ICD-10 coding systems accurately for CCM, RPM, and RTM documentation and billing purposes.
- Collaborate with healthcare providers, social workers, behavioral health specialists, and care teams to develop comprehensive care coordination, discharge planning, and follow-up strategies.
- Manage medical records meticulously, ensuring HIPAA compliance and patient data confidentiality at all times.
- Conduct patient intake assessments to identify clinical, psychosocial, and technology-readiness needs related to chronic care, RPM, and RTM enrollment.
- Support discharge planning by coordinating post-acute services, RPM enrollment, patient education, and self-management tools.
- Maintain thorough, timely documentation of patient interactions, medical terminology, treatment plans, monitored data, and progress in electronic health records (EHRs).
- Engage patients through phone, digital tools, and monitoring platforms to promote understanding of medical conditions and sustained participation in care programs.
Essential Functions:
- Complete individualized patient-centered care plans and provide management services using CCM software.
- Maintain frequent patient contact to coordinate care, provide support, and ensure program compliance to improve outcomes.
- Communicate emergent needs or life-threatening episodes to Psychiatric Clinicians.
- Accurately document all verbal and written client communications in a timely manner.
- Manage a caseload of up to 500 members.
- Coordinate with schedulers to set and verify all required patient appointments.
- Manage referrals and review member medications as necessary.
- Qualify members for end-of-month billing and add them to the billing system.
- Create and update care plans and review member charts as needed.
Qualifications:
- Prior experience in Chronic Care Management (CCM) with Remote Patient Monitoring (RPM) and/or Remote Therapeutic Monitoring (RTM) is strongly preferred.
- Proven experience working in hospital, acute care, ambulatory, or virtual care settings.
- Strong knowledge of medical coding practices, including CPT, ICD-9, ICD-10, and familiarity with CCM, RPM, and RTM billing requirements.
- Experience with remote monitoring platforms, connected health devices, or therapeutic tracking tools is highly desirable.
- Familiarity with behavioral health integration, social work principles, and pediatrics is an advantage.
- Demonstrated experience in discharge planning, care coordination, intake assessments, and case management.
- Excellent attention to detail in managing documentation, medical records, and compliance requirements.
- Ability to communicate effectively with multidisciplinary teams while maintaining strict HIPAA compliance.
- Background in medical coding, healthcare administration, or population health management is a strong asset.
Preferred Skills:
- Strong oral, written, and phone communication skills. Ability to work independently with excellent organization and time management. Knowledge of clinical practices, diagnostic procedures, and treatment protocols. Strong clinical judgment and critical thinking skills. Ability to build trusting relationships with patients and partner practices in a fast-paced environment. Results-oriented with a focus on quality and daily productivity. Proven problem-solving, consultative, and customer service skills
