Chronic Care Coordinator

  • STATUS: Full Time
  • Omaha, Ne

Website H3C, LLC


Our Telephonic Chronic Care Coordinator (CNA) position is in Omaha, NE.

The Chronic Care Management Program provides Chronic Care Management (CCM) to patients with two or more chronic diagnoses. CCM collects patient-centric health information to identify gaps in care and chronic risks.

The CCM program requires the development of a Patient-Centric Care Plan that provides goals and interventions to implement, monitor and support the needs of the patient as defined by the PCP.

Collaboration with the primary care provider to ensure all care needs are addressed and interventions are clinically appropriate is an essential program function.

The CCM program supports the patient through the continuum of care to promote the highest level of quality carePatient CCM interventions are at a minimum monthly with updates of a PCP approved Care Plan.

Essential Duties and Responsibilities:

  • Educate the patient in the role of the care coordinator with collaboration of primary care physician.
  • Provide an initial risk identification function gathering all the clinical elements necessary to determine Patient Centric Care Plan.
  • Monitor recidivism in ER and inpatient utilization.
  • Evaluation transition care needs for documented recidivism and implement interventions to address failures of transitional care.
  • Work with patient to plan and monitor their care as determined by the PCP and/specialist.
  • Promote compliance with transitional care, PCP/Specialist office visits.
    Promote compliance with medication (medication adherence).
  • Act as a patient advocate, liaison and information resource.
  • Provide chronic care education for chronic/complex conditions as determined.
  • Gather and report outcomes to Care a Plan goals and interventions at a minimum monthly.
  • Facilitate patient access to appropriate medical and specialty providers as defined by the PCP.
  • Cultivate and support primary care and specialty provider who determine the care needs of the patient.

Provide culturally appropriate education.

Other Responsibilities:

  • Adheres to the policies and procedures of H3C, LLC.
  • Maintains strict confidentiality of client, company and personnel information
  • Demonstrates a strong commitment to the mission and values of the organization
  • Adheres to company attendance standards

Performs other duties as assigned


  • 3 to 5 years’ experience in, clinical or community resource setting (care coordination experience is desirable).
  • Experience with supporting patients with chronic diseases.
  • Familiarity with support of geriatric patients.
  • Motivation interviewing desirable.
  • Proficiency in communication technologies for example email, excel and EMR.
  • Highly organized with ability to keep accurate notes and records.

Education and/or Experience:

High School diploma required

CNA Current Certified Nursing Assistant.

Additional state certification may be necessary depending on ACO location when reciprocity is available.

Environmental Factors/Physical Demands:

Work is performed in an call center environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor.

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