Phamily Care Coordinator (North Carolina Nephrology)

Wilson, United StatesOn-site

Responsibilities

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.
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.
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. Experience 1–3 years of

experience in a healthcare setting involving patients with complex chronic diseases (preferred). Skills &
Strong working knowledge of chronic kidney disease (CKD).
Strong interpersonal skills and the ability to engage with a wide variety of patients and teams.
Proficiency in reading, writing, and verbal communication.
Basic computer proficiency, including
experience using Electronic Health Records (EHRs). Work Environment

Phamily is assisting North Carolina Nephrology in hiring a Phamily Care Coordinator to support nephrologists and advanced practitioners in managing chronic care patients.
This role involves using the Phamily Chronic Care Management platform to improve patient care, prevent unnecessary hospitalizations, and enhance communication between patients and their care teams. Summary of Duties