Remote Chronic Care Management (CCM) Coordinator
- Proactively contact assigned panel of patients to assess health status, medication adherence, barriers to care, and self-management needs.
- Educate and coach patients on chronic conditions, preventive care, and care plan goals in collaboration with providers.
- Obtain verbal consent and enroll eligible patients into CCM programs.
- Develop, update, and maintain individualized care plans based on patient needs and provider direction.
- Track and document all interactions, care activities, and care plans in the EHR or care management platform to meet documentation and billing standards.
- Coordinate follow-ups, referral tracking, and patient reminders for appointments and preventive services.
- Identify social determinants of health and connect patients with appropriate community resources.
- Work with primary care providers, nurses, and care teams to share updates and escalate clinical concerns.
- Participate in care team meetings and contribute to continuous quality improvement efforts tied to chronic care measures.
- Maintain compliance with CMS CCM requirements and organizational protocols.
- Clinical background (Medical Assistant, LPN, RN) or equivalent experience in care coordination or healthcare support roles.
- Experience with chronic disease management, patient education, or care coordination.
- Strong communication skills and comfort engaging patients by phone and digital tools.
- Ability to work independently in a remote environment with reliable internet access.
- Proficiency with electronic health records and care management platforms.
- Prior experience in Chronic Care Management, Remote Patient Monitoring, or similar population health programs
- Knowledge of CMS CCM billing, documentation, and time tracking requirements
- Experience working in an electronic medical record (EMR) system, preferably in a primary care or ambulatory setting
- Comfort navigating multiple technology platforms while delivering remote patient care
- Bilingual skills a plus
- Fully remote, regular business hours with occasional flexibility based on patient needs.
- This role does not require in-person clinic presence but includes close coordination with the Care/Ops Team
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