Phamily Care Coordinator

Job Description

Job Description

Phamily Care Coordinator Summary of Duties

The Phamily Care Coordinator is responsible for providing care management services to patients enrolled in Chronic Care Management (CCM) programs. These patients often have chronic conditions such as chronic kidney disease, diabetes, hypertension, and other renal-related diagnoses. Working in collaboration with patients, clinic providers, and community resources, the Care Coordinator plays a key role in enhancing patient self-management, engagement, and shared decision-making.

• Manage initial enrollment and ongoing registration of CCM patients.
• Validate CCM patient enrollment per current NCN guidelines.
• Ensure PHI consent is completed prior to any health-related communication.
• Aim for a minimum of 20 minutes of Phamily/telephonic communication per patient each month.
• Comply with CCM documentation requirements by reinforcing care plans and documenting interactions in both Phamily and the EHR.
• Monitor patient adherence to care plans, track progress, evaluate effectiveness, and recommend adjustments as needed.
• Facilitate patient and caregiver engagement by offering appropriate levels of care coordination based on individual needs.
• Support patient access to appropriate clinical staff and providers.
• Coordinate transitions from inpatient to outpatient care to reduce hospital readmission risk.
• Collaborate with clinical staff and in-office providers to manage day-to-day Phamily messages, including symptom control, medication questions, and patient education.
• Educate patients and caregivers about relevant community resources.
• Assist in identifying high-risk patients with chronic conditions or special healthcare needs.
• Coordinate continuity of care across healthcare organizations and facilities.
• Encourage patient self-management and provide behavior modification support.
• Deliver health counseling, education, and coaching in collaboration with the NC Nephrology team.

• 1–3 years of experience in a healthcare setting involving patients with complex chronic diseases (preferred).

• Strong working knowledge of chronic kidney disease (CKD).
• Self-starter with a results-oriented mindset.
• Excellent organizational, communication, time management, and multitasking abilities.
• Strong interpersonal skills and the ability to engage with a wide variety of patients and teams.
• High-level customer service with a track record of positive patient and team feedback.
• Problem-solving abilities with a proactive approach.
• Proficiency in reading, writing, and verbal communication.
• Basic computer proficiency, including experience using Electronic Health Records (EHRs).

• In-person role based at the Wilson Office.
• Responsibilities, skills, and working conditions may evolve based on program needs.