• Chronic Care Coordinator

    Job Locations US-VA-Roanoke
    Job ID
  • Overview

    The Chronic Care Coordinator is responsible for managing a system of behavioral health chronic care interventions specific to individuals with complex medical or behavioral health conditions and psychosocial risks. This role is primarily telephonic and will be responsible for the coordination of behavioral health services that will promote positive health outcomes, emphasize prevention of exacerbations and complications, teach patient self-management skills and identify patients appropriate for Chronic Care coordination. 


    • Early identification of at-risk Virginia Premier members with behavioral health Chronic Care issues for intervention.
    • Provide behavioral health Chronic Care services, mostly telephonic, according to VPHP’s policies and procedures to assess the member’s current health and psycho-social status, resource utilization and past and present treatment plans and services.
    • Chronic Care Coordination will involve working with members who may have a medical condition that may involve inpatient care in a hospital, hospice, or residential medical care facility; and require continuing treatment by a health care provider for 3 months or more. Examples of these conditions are Hypertension; Asthma; Diabetes; Cancer; Hypercholesterolemia; Heart Disease; Arthritis; COPD and Obesity. Members within chronic care coordination will be individuals ages 18 and older, who have serious mental illness diagnosed under the DSM in the following major diagnostic categories: schizophrenias and other psychotic disorders, bipolar disorders, and major depressive disorders. Members may also include women identified as experiencing prenatal or postpartum mental illness.
    • Initiate contact with member, family, and behavioral health care providers to coordinate services.
    • Conducts a comprehensive assessment of the member’s health and psychosocial needs, including health literacy status and deficits.
    • Develop, coordinate and implement behavioral health Chronic Care Plan. Maintains records documenting the plan of care
    • Continuously monitor, reassess and re-evaluate that the treatment plan remains appropriate.
    • Identify gaps or barriers preventing the member from following through with a recommended treatment plan consistent with optimal care for specified disease condition
    • Provide behavioral health education to assist/teach self -management skills
    • Provides information on network access and identifies and implements behavioral health interventions and resources that address and close gaps in behavioral health care
    • Close cases according to the defined case closure procedure
    • Assists in analyzing and reviewing data to monitor performance outcomes
    • Researches, evaluates and recommends behavioral health and social service community resources to meet the non-medical needs of members
    • Maintains behavioral health Chronic Care resources, keeping information current
    • Plan behavioral health Chronic Care team conference, and other meetings as needed to discuss care options.
    • Acts as a liaison to promote an effective working relationship with behavioral health providers (including vendors).
    • The behavioral health Chronic Care coordinator shall serve as an informed resource on Premier’s policies and benefits to all providers
    • Participates in continuing educational activities as appropriate, in the orientation and training of case management staff,  and Premier’s ongoing quality improvement process
    • Assists in the ongoing development of programs and projects to enhance/expand Chronic Care resources to meet member needs
    • Maintains confidentiality of member information and Premier’s proprietary operational information



    • Registered Nurse licensed in Virginia or
    • Licensed Mental Health Professional in the State of Virginia
    • Bachelor's of Science degree in Nursing (BSN) preferred
    • Master’s Degree in Health or Human Services preferred
    • Certified Case Manager preferred


    • Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employee
    • PC literate with a strong working knowledge of Microsoft Word, Excel spreadsheet programs and various computer software programs
    • Working knowledge of resource options, and experience in making appropriate referrals
    • Possess a working knowledge of ICD-10, DSM, and CPT coding
    • Knowledge of Community Resources


    • Minimum 2 years’ experience working with individuals with mental health, substance use and/or developmental disabilities
    • Current behavioral health clinical experience and/or management care experience
    • Demonstrated ability to work effectively in multi-disciplinary teams
    • Experience working with prenatal and postpartum women
    • Experience working with low income and disadvantage populations with behavioral health issues
    • Experience in the recovery model of care
    • Experience working with Community Service Boards, State Psychiatric Hospitals, Freestanding Psychiatric Hospitals, and/or Developmental Disability training facilities


    • Physical health sufficient to meet the ergonomic standards and demands of the position.

    About Us


    Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


    We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


    Our mission is to inspire healthy living within the communities we serve!


    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed

    Need help finding the right job?

    We can recommend jobs specifically for you! Click here to get started.