Chronic Care Management Specialist

Job Description

Job Description

Position Summary

We are seeking an experienced and compassionate Chronic Care Management (CCM) Specialist to join our growing healthcare team. In this role, you will serve as the primary point of contact for patients enrolled in Chronic Care Management programs, helping them navigate their healthcare journey, improve health outcomes, and maintain adherence to individualized care plans. The ideal candidate has prior CCM experience, is proficient in eClinicalWorks (eCW) , and is passionate about delivering exceptional patient-centered care.

Key Responsibilities

• Manage and coordinate care for patients enrolled in Chronic Care Management (CCM) programs.
• Conduct patient outreach through phone calls and other communication methods to encourage engagement and participation.
• Develop, maintain, and update individualized patient care plans.
• Monitor patient progress and ensure compliance with physician-directed care plans.
• Coordinate healthcare services and connect patients with appropriate community and medical resources.
• Accurately document patient interactions, care activities, and clinical updates within eClinicalWorks (eCW) .
• Collaborate with physicians, nurses, caregivers, and healthcare staff to ensure continuity of care.
• Educate patients regarding chronic disease management, medications, appointments, and preventive care.
• Maintain confidentiality and compliance with HIPAA and organizational policies.
• Support quality improvement initiatives aimed at enhancing patient outcomes and satisfaction.

Required Qualifications

• Previous experience in Chronic Care Management (CCM) .
• Hands-on experience using eClinicalWorks (eCW) .
• High school diploma or equivalent required.
• Strong verbal and written communication skills.
• Excellent organizational, documentation, and time-management abilities.
• Ability to work independently while collaborating effectively within a healthcare team.
• Comfortable with frequent patient outreach and phone-based communication.
• Strong attention to detail and ability to maintain accurate records.
• Compassionate, professional, and patient-focused approach to care.
• Working knowledge of HIPAA regulations and patient confidentiality standards.

Preferred Qualifications

• Associate's or Bachelor's degree in Healthcare Administration, Nursing, Public Health, or a related field.
• Additional experience in care coordination, case management, population health, or patient advocacy.
• Experience working in primary care, family medicine, internal medicine, or specialty healthcare practices.
• Bilingual (English/Spanish) communication skills.
• Knowledge of Medicare Chronic Care Management guidelines and documentation requirements.
• Certification related to care coordination, medical assisting, or healthcare administration is a plus.
• Proven ability to build strong relationships with patients and healthcare providers.

Physical Requirements

• Ability to remain seated for extended periods while working on a computer and telephone.
• Frequent use of a computer, keyboard, headset, and other office equipment.
• Ability to communicate effectively with patients, providers, and team members via phone and video conferencing.
• Ability to read, analyze, and accurately document patient information.
• Occasional standing, walking, bending, and reaching as needed in an office environment.
• Ability to maintain focus and productivity in a fast-paced healthcare setting.

Company Description

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