Chronic Care Management

• Manage a panel of CCM and TCM patients, ensuring timely outreach, documentation, and completion of required program elements.
• Conduct patient outreach, follow-ups, and education to support chronic disease management.
• Assist with medication reconciliation, referrals, and care coordination.
• Support patients in navigating appointments, labs, imaging, and community resources.
• Document all care management activities accurately and consistently in the EHR.
• Provide care management, including phone-based outreach and in office patient support as needed.

• Work closely with physicians, supervisors, and clinical staff to support patient care plans.
• Follow established CCM and TCM workflows to ensure consistency and compliance.
• Escalate concerns, barriers, or process improvement ideas through leadership channels.
• Participate in team meetings and ongoing training.

• Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role.
• Patient centered and Team oriented
• Medical Assistant experience preferred .
• Organized, dependable, and able to work independently within defined workflows.
• Able to follow structured workflows while maintaining strong attention to detail and accountability for assigned tasks.
• Understands role responsibilities and maintains appropriate professional boundaries within a team-based care model.
• Able to manage a high-volume workload, prioritize tasks effectively, and meet deadlines in a fast-paced environment.
• Communicates clearly and proactively with leadership regarding patient needs, barriers, and workflow concerns.
• Open to feedback, coaching, and professional development.
• Experience with Athena EHR or similar systems preferred.

• Supportive leadership with clear expectations, structured workflows, and accountability.
• Established systems that allow you to focus on patient care without unnecessary chaos.
• Opportunities to build skills in CCM, TCM, and care coordination.
• A collaborative environment that values teamwork, consistency, and growth.
• Meaningful work that helps reduce hospitalizations and improve patient outcomes.