Job DetailsJob Location: Homewood Main Campus - BIRMINGHAM, AL 35209The Chronic Care Coordinator supports patients enrolled in CMS Chronic Care Management (CCM) programs by delivering non–face-to-face care coordination services in accordance with Medicare guidelines. This remote role focuses on managing patients with two or more chronic conditions through ongoing monitoring, care plan management, patient education, and care team collaboration to improve outcomes and reduce avoidable utilization.

Key Responsibilities

· Provide CMS-compliant Chronic Care Management (CCM) services for eligible Medicare patients with two or more chronic conditions expected to last at least 12 months.

· Conduct non–face-to-face patient outreach via phone, secure messaging, and telehealth platforms to meet monthly CCM time requirements.

· Develop, document, and maintain comprehensive electronic care plans addressing medical, functional, psychosocial, and preventive care needs.

· Perform monthly care coordination activities, including medication reconciliation support, appointment coordination, and follow-up on care gaps.

· Educate patients and caregivers on chronic disease management, medication adherence, lifestyle modifications, and self-management strategies.

· Identify and address barriers to care, including social determinants of health, and connect patients with community and clinical resources.

· Coordinate communication between patients, primary care providers, specialists, pharmacies, and other care team members.

· Accurately track, document, and report billable CCM time in compliance with CMS guidelines and organizational policies.

· Ensure patient consent for CCM services is obtained, documented, and maintained per CMS requirements.

· Support quality measures, risk stratification efforts, and care gap closure initiatives.

· Maintain strict compliance with HIPAA, CMS regulations, and internal compliance standards.
QualificationsHS Diploma or equivalent required. 

· Demonstrated background in medical knowledge through relevant healthcare experience, such as:

o Chronic Care Management (CCM), care coordination, or case management roles

o Medical assistant, patient navigator, health coach, EMT, CNA, LPN, or similar healthcare positions

o Healthcare documentation, EHR management, or clinical support experience

· 1–3 years of experience in healthcare, population health, or chronic care support preferred.

· Familiarity with CMS CCM guidelines, billing concepts, and documentation standards strongly preferred.

· Experience working with Medicare populations and chronic disease management preferred.

· Prior remote healthcare or telehealth experience is a plus.

Required Skills & Competencies

· Strong understanding of chronic disease states, medical terminology, and care coordination workflows.

· Knowledge of CMS CCM requirements, including care plans, patient consent, and time tracking.

· Excellent verbal and written communication skills for remote patient engagement.

· High attention to detail and strong documentation skills to support compliance and billing accuracy.

· Ability to manage a remote caseload and meet monthly CCM time thresholds.

· Proficiency with EHR systems, care management platforms, and telehealth tools.

· Ability to work independently while collaborating with clinical and administrative teams.

· Patient-centered, empathetic approach with strong problem-solving skills.

· Reliable high-speed internet and a private, secure workspace.

Work Environment

· Fully remote, work-from-home position.

· Requires frequent phone, messaging, and computer use throughout the workday.

Physical Requirements

· Ability to sit and work at a computer for extended periods.

· Ability to manage sensitive patient information and emotionally complex patient interactions