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.