Advanced Primary Care Management (APCM) Care Coordinator

Job Description

Chandra Britt Armstrong MD, LLC is seeking a very friendly, highly organized, compassionate, and mission-driven Clinical Care Coordinator to lead our proactive Advanced Primary Care Management (APCM) and Remote Patient Monitoring (RPM) programs. This critical position is designed to transition our complex, multi-chronic geriatric cohort from reactive episodic treatment to a continuous, relationship-based safety net. Operating under the general supervision of Dr. Armstrong, you will serve as the chief navigator of care, helping patients manage their conditions at home, coordinating community resources, closing acute hospital discharge transitions, and ensuring that no senior feels left alone in managing their health.

Core Responsibilities

· Patient Onboarding & Informed Consent: Conduct dedicated outreach to eligible Medicare beneficiaries, explain the physical and clinical benefits of the APCM and RPM programs in warm, senior-friendly terms, secure and document patient informed consent inside the EHR, and clarify cost-sharing structures.

· Comprehensive Care Plan Development: Establish, record, and maintain personalized, dynamic electronic comprehensive care plans within AthenaOne. Perform systematic physical, cognitive, functional, and psychosocial needs assessments (including Social Determinants of Health screening).

· Dynamic Symptom Management: Educate patients and caregivers on customized, patient-friendly Green/Yellow/Red exacerbation action plans (covering Hypertension, Type 2 Diabetes, CHF, and COPD). Ensure all enrolled participants understand how and when to contact the clinic's dedicated 24/7 care support lines.

· Hospital Transitions of Care (7-Day Rule): Audit the daily hospital discharge queue. Execute clinical contact with recently discharged patients within 48 hours of inpatient or emergency department release, complete formal medication reconciliations, identify acute functional/social barriers, and coordinate priority post-acute appointments within the mandated 7-day window.

· Behavioral Health Collaboration: Identify patient indicators for integrated mental health needs and coordinate direct handoffs to our on-staff Licensed Clinical Social Worker (LCSW) for Psychiatric Collaborative Care (CoCM) support.

· After-Hours Handoff Review: Audit the Overnight Call and Triage Log submitted by our clinical partner (VP Scribes) in AthenaOne every morning within 2 hours of clinic opening. Immediately follow up on any patient-reported clinical alerts or socioeconomic needs.

· Interprofessional Care Coordination: Liaise with external consulting specialists, home health agencies, community service organizations, and caregivers to securely exchange health data, close preventive care gaps, and synchronize patient-centered clinical goals.

Performance & Operational Standards

Unlike legacy care management programs that rely on rigid minute-tracking stopwatches, Medicare's APCM model is activity-based, prioritizing clinical quality and proactive patient outcomes. Performance is measured by your focus and consistency in the following areas:

· Program Enrollment Activity: Consistently engage 20–50 eligible patient touches weekly to support onboarding goals and maintain program momentum.

· ED Diversion Rate: Effectively utilize Green/Yellow/Red action plans to guide patients to telephone or clinic-based triage, successfully reducing preventable ED presentations.

· Handoff Documentation Lag: Ensure all clinical triage calls, transitional care plans, and after-hours events are documented and routed within AthenaOne in less than 2 hours to prevent morning care gaps.

· MIPS Quality Reporting: Accurately document preventive care metrics and social assessments within the AthenaOne system to satisfy the clinic's Value in Primary Care MIPS Value Pathway (MVP) objectives.\nCompany Description

At Chandra Britt Armstrong MD, LLC, we are dedicated to providing top-quality medical care to all of our patients. Our team of experienced healthcare professionals is committed to ensuring your well-being and providing you with personalized care that meets your unique needs. We offer a wide range of medical services, including preventive care, diagnostic testing, and treatment for acute and chronic conditions. Our state-of-the-art facilities are equipped with the latest technology to ensure accurate diagnoses and effective treatments.Our role in this African American Community is Critical for Healthcare services.

Chandra Britt Armstrong MD, LLC is an equal-opportunity employer committed to diversity and inclusion in the workplace. We welcome applicants from all backgrounds to apply.

Full-time