Clinical Care Coordinator, APCM & Remote Patient Monitoring
Overview
Own the APCM and RPM programs for a geriatric cohort, transitioning care from reactive to proactive. You'll guide patients through onboarding, care plans, and transitions, coordinating with AthenaOne and community partners. Work directly under Dr. Armstrong in a mission-driven clinic serving the African American community. This role centers on building relationships and ensuring no senior manages their health alone.
What You'll Do8
- 1Conduct outreach to Medicare beneficiaries, explain APCM and RPM benefits, secure informed consent in AthenaOne, and clarify cost-sharing.
- 2Build personalized care plans in AthenaOne after assessing physical, cognitive, functional, and psychosocial needs, including SDOH screening.
- 3Educate patients on Green/Yellow/Red action plans for Hypertension, Type 2 Diabetes, CHF, and COPD, ensuring 24/7 support line access.
- 4Audit the hospital discharge queue and complete 48-hour post-discharge contact, medication reconciliation, and 7-day follow-up scheduling.
- 5Identify behavioral health needs and hand off to the on-staff LCSW for CoCM support.
- 6Review overnight call logs in AthenaOne within 2 hours of clinic opening and follow up on alerts.
- 7Liaise with specialists, home health agencies, and community groups to close care gaps and align goals.
- 8Document preventive metrics and social assessments in AthenaOne to meet MIPS objectives.
Requirements8
- 12+ years in clinical care coordination or related healthcare role.
- 2Experience with EHR systems, specifically AthenaOne preferred.
- 3Knowledge of Medicare and CPT codes for APCM and RPM billing.
- 4Familiarity with chronic conditions: Hypertension, Type 2 Diabetes, CHF, COPD.
- 5Strong communication skills with elderly patients and families.
- 6Proficiency in documenting within 2 hours of clinical encounters.
- 7Understanding of SDOH and community resources.
- 8Ability to manage 20-50 patient touches weekly.
Salary Insight
$37 - $48k per year
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