Chronic Care Management Coordinator

Overview

We are seeking a Licensed Practical Nurse (LPN) or experienced Medical Assistant (MA) to oversee our Chronic Care Management (CCM) program. The LPN/MA will coordinate care for patients with chronic conditions, ensuring high‑quality support, compliance with CMS guidelines, and improved patient outcomes.

• Conduct monthly outreach calls to assigned patients.
• Monitor and record patient‑reported symptoms, medication adherence, and barriers to care.
• Reinforce patient self‑management goals as outlined in the care plan.
• Coordinate referrals, appointments, labs, and testing.
• Collaborate with providers, specialists, and support services.
• Identify and escalate clinical concerns to the provider.
• Review current medications with patient.
• Maintain accurate documentation and ensure billing compliance.

• Current LPN license, active and in good standing.
• 2+ years’ clinical experience (chronic disease preferred).
• Strong communication and patient education skills.
• Proficient in EHR systems and documentation. ECW experience a plus but not required.
• Ability to work independently while following clinical protocols.
• Patient‑centered, organized, detail‑oriented, collaborative, and compassionate.

• Work is performed in an office work environment.
• Very limited physical effort is required.
• Limited exposure to physical risk.