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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.

Key Responsibilities:

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.

Qualifications and Skills:

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 Conditions:

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

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Apply for Chronic Care Management Coordinator at Digestive Disease Consultants