Chronic Care Management Coordinator

Digestive Disease Consultants

Altamonte Springs, Florida

JOB DETAILS
SKILLS
Billing Records, Chronic Disease, Clinical Medicine, Clinical Practices/Protocols, Communication Skills, Content Management Systems (CMS), Customer Support/Service, Detail Oriented, Documentation, Health Plan, Laboratory Testing, Licensed Practical Nurse/Licensed Vocational Nurse, Maintain Compliance, Medical Assistance, Medical Record System, Medical Records, Medications, Organizational Skills, Patient Care, Patient Education, Plan Meetings, Risk, Team Player
LOCATION
Altamonte Springs, Florida
POSTED
18 days ago
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.

About the Company

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Digestive Disease Consultants