Centered in a clinician provider practice, this individual works in partnership with patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines. Coordinates care for patients with chronic disease and manages effective care transitions for them within the continuum. Partners with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness.
Provides effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk. Promotes effective partnerships and utilization of community resources. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family-centered.
Qualifications
High School diploma or GED required; post-secondary education preferred, medical assistant certification required.
Previous 3 years medical experience, preferably in an office/clinic setting caring for chronic disease patients. Preferable knowledge/experience with MCR Annual Wellness Visits, Transition Care Management, and Care Gap documentation, components, and billing. Preferable experience in social or case work.
Additional Skills/Abilities : Core values consistent with a patient/family-centered approach to care, demonstrates professional and effective written and verbal communication skills, demonstrates a positive, respectful attitude and professional customer service, acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations, proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns, recognizes and responds to opportunities for improvement., demonstrates continual learning skills, effects changes in approach to care based on established, evidence-based practice, demonstrates professional practice behavior, cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members), demonstrates understanding in use of IT resources and patient databases, demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.
Build your career with us At Huntsville Hospital, Huntsville Hospital for Women & Children and Madison Hospital, you’ll find meaningful work, supportive teams and opportunities to grow within a locally governed, nonprofit health system committed to the communities we serve. Our workplace culture has earned national recognition, including Newsweek’s America’s Greatest Workplaces in Health Care 2026 and Forbes’ America’s Best-in-State Employers 2025.
Huntsville Hospital is the region’s primary referral center for advanced and specialty care, home to a specialized Orthopedic & Spine Tower, a Level III Regional Neonatal ICU and North Alabama’s Level I Trauma Center. Together, our three Madison County hospitals have 971 licensed beds and offer career opportunities across a wide range of specialties and care settings. Employees have access to continuing education, Shared Governance, Clinical Ladder, Nurse Residency, tuition assistance, child care, wellness resources, an on-site employee pharmacy and health clinic, and more.
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We are committed to providing competitive benefits. Our benefits package for eligible employees includes medical, dental, vision, life insurance, flexible spending; short term and long term disability; several retirement account options with 401K organization match; nurse residency program; tuition assistance; student loan reimbursement; On-site training and education opportunities; Employee Discounts to phone providers, local restaurants, tickets to shows, apartment application and much more!
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