Chronic Care Management Team Lead

Chronic Care Management Team Lead – LPN or Experienced Medical Assistant (MA)

Alliance Medical Clinic | Desert Valley Palliative Care

Location: Phoenix, Arizona - Hybrid (Primarily Remote)

Job Type: Full-Time

Compensation:

• Medical Assistant (MA): $24-$26 per hour , based on experience.
• Licensed Practical Nurse (LPN): $34 per hour.

Position Overview:

We are seeking an experienced, medically knowledgeable, and highly motivated Chronic Care Management Team Lead to join our growing primary care, mobile medical, and palliative care programs.

This individual will work closely with our existing care management coordinator, physicians, nurse practitioners, and interdisciplinary clinical team to help oversee daily care management activities, improve patient outcomes, and ensure continuity of care for patients with chronic and complex medical conditions.

The ideal candidate has strong clinical knowledge, excellent organizational skills, leadership abilities, and experience in chronic disease management, patient education, or care coordination.

This is a hybrid position, primarily working from home, with occasional visits to our medical offices, assisted living facilities, skilled nursing facilities, and other patient care locations.

Key Responsibilities:

Team Leadership & Program Support:

• Help lead daily Chronic Care Management (CCM) activities and support the care management team.
• Collaborate with the existing care management coordinator to ensure efficient workflows, patient follow-up, and timely documentation.
• Monitor patient outreach, care plan completion, and overall program performance.
• Assist with staff education, workflow improvements, and quality assurance.
• Identify opportunities to improve patient engagement, operational efficiency, and care management outcomes.
• Serve as a clinical resource within the limits of professional training and licensure.

Chronic Disease Management:

• Support ongoing management of patients with diabetes, hypertension, congestive heart failure, COPD, coronary artery disease, dementia, and other chronic illnesses.
• Review patient medical histories, medications, and treatment plans.
• Monitor patient needs through regular telephone outreach and follow-up.
• Identify changes in patient status and elevate concerns to appropriate providers.
• Assist with care plan development, implementation, and follow-up.
• Coordinate appointments, referrals, diagnostic testing, and specialty care.
• Support medication reconciliation, adherence, and patient education within scope of practice.

Quality Measures & Population Health:

• Identify and help close gaps in care, including preventive screenings, laboratory monitoring, vaccinations, and chronic disease follow-up.
• Support HEDIS, Medicare Advantage, and value-based quality initiatives.
• Coordinate Medicare Annual Wellness Visits and preventive health services.
• Assist with chronic condition documentation and risk adjustment initiatives.
• Track quality outcomes and identify opportunities for improvement.

Transitional Care Management:

• Coordinate care for patients discharged from hospitals, rehabilitation centers, and skilled nursing facilities.
• Ensure timely post-discharge outreach and follow-up appointments.
• Review discharge instructions, medication changes, and ongoing care needs.
• Communicate with patients, caregivers, providers, and facilities.
• Help reduce unnecessary emergency department visits and hospital readmissions.

Mobile Medicine & Palliative Care:

• Support care management for homebound, medically complex, and palliative care patients.
• Collaborate with mobile physicians, nurse practitioners, facility staff, and home health agencies.
• Identify patients who may benefit from additional medical, palliative, or supportive services.
• Participate in occasional facility visits for patient follow-up, education, and care coordination.
• Assist with communication among patients, families, caregivers, and providers.

Patient Education & Care Coordination:

• Educate patients regarding chronic illnesses, medication adherence, preventive care, and treatment plans.
• Identify barriers to healthcare, including transportation, financial limitations, medication access, and caregiver support.
• Coordinate community resources and support services.
• Maintain accurate documentation in the electronic medical record.
• Help support CCM, Principal Care Management (PCM), Advanced Primary Care Management (APCM), and Transitional Care Management (TCM) programs.

Qualifications:

Required:

• Active Arizona LPN license or medical assistant training with substantial clinical experience.
• Strong understanding of common medical conditions, medications, and clinical terminology.
• Prior experience in primary care, internal medicine, chronic care management, population health, or a related clinical setting.
• Strong critical-thinking, communication, and organizational abilities.
• Ability to work independently and help provide leadership to a growing team.
• Proficiency with electronic medical records and computer-based workflows.
• Ability to make occasional visits to medical offices and healthcare facilities.

Preferred:

• Experience with Medicare CCM, PCM, APCM, or TCM programs.
• Experience in geriatrics, palliative care, home health, or skilled nursing.
• Understanding of HEDIS, Medicare Advantage quality measures, and gaps in care.
• Experience with patient caseload management and quality improvement.
• Previous team lead or supervisory experience.

What We Offer:

• Competitive compensation based on professional credentials and experience.
• Primarily work-from-home schedule with occasional local travel.
• Opportunity to help lead and expand a growing chronic care management program.
• Collaboration with physicians, nurse practitioners, and an established healthcare team.
• Exposure to primary care, mobile medical services, palliative care, and population health.
• Opportunities for professional growth and additional leadership responsibilities.

Ideal Candidate:

We are looking for someone who brings strong medical knowledge, leadership potential, sound clinical judgment, and a proactive approach to patient care .

This position is ideal for an experienced LPN or medical assistant who wants to take on greater responsibility, help guide a care management team, and make a meaningful difference in the lives of medically complex patients.

Join Alliance Medical Clinic and Desert Valley Palliative Care as we continue expanding our chronic care management and population health programs.