Chronic Care Management Coordinator (LPN or MA)

Job Description

Job Description

We are seeking an experienced   skilled clinical Care Coordinator to join our Chronic Care Management (CCM) program. This is a fast-paced, patient-centered role that requires strong communication skills, excellent organization, and the ability to manage multiple priorities across several patients each day. This role is ideal for a clinician who thrives in proactive care coordination, complex chronic disease management, and patient outreach.

About Us

The Westchester Institute for Human Development (WIHD) provides the broadest array of heath services and medical specialties in Westchester County and beyond to serve the needs of individuals with intellectual and developmental disabilities. In addition to primary care, we offer many behavioral health resources including psychiatry, neurology behavioral psychology.

About the Role

We are seeking a detail-oriented and proactive Care Coordinator to support our Chronic Care Management (CCM) program. In this role, you will work directly with patients, caregivers, and providers to help close care gaps, improve health outcomes, and ensure patients receive timely, coordinated care.

You will be responsible for conducting structured CCM outreach calls, reviewing patient charts, coordinating follow-up care, and documenting all interventions in the electronic medical record (EMR).

Essential Functions of the CCM position include:

CCM Patient Outreach

• Conduct scheduled Chronic Care Management calls with assigned patients
• Review patient charts prior to each call to identify care gaps and outstanding needs
• Follow up on appointments, referrals, labs, imaging, and provider recommendations
• Support patients in understanding and following their care plans

Care Coordination

• Assist patients with scheduling appointments during outreach calls when possible
• Track missed, overdue, or pending healthcare services
• Coordinate with providers, specialists, and internal care teams
• Ensure continuity of care following hospital or emergency visits

Medication & Treatment Support

• Review medication lists for updates or discrepancies
• Identify refill needs and coordinate with providers
• Document medication-related concerns and patient adherence issues

Documentation & Compliance

• Accurately document all CCM encounters in the EMR
• Ensure notes are patient-specific, detailed, and reflect actions taken
• Track all follow-up items until resolution
• Maintain compliance with CCM program requirements

Pre-Call Preparation (Required)

• Review provider notes, orders, and patient history prior to each call
• Identify overdue appointments, referrals, and diagnostic tests
• Confirm chart accuracy and care plan status before outreach

Qualifications

Education, Licensure, Certification:  Active licensure, registration, or certification in a related healthcare field (such as Nursing or Certified Clinical Medical Assistant) is required and must be maintained in good standing.

Experience and Knowledge:

• 2+ years of experience in a healthcare or administrative clinical setting 
• 2+ Experience with medical scheduling, referrals, or patient coordination 
• Working knowledge with electronic medical records (EMR) systems 
• Strong attention to detail and documentation accuracy 
• Excellent communication skills (written, phone, email, and patient-facing interaction) 
• Ability to work independently while following structured workflows
• Strong clinical judgment, chart review skills, and EMR proficiency 
• Ability to manage high-volume patient panels independently

Preferred Qualifications

• Experience in Chronic Care Management (CCM) or care coordination 
• Experience working with patients with chronic conditions or complex care needs 
• Knowledge of medical terminology and healthcare workflows 
• Experience with insurance, referrals, or prior authorizations 

Benefits

• Medical and Dental Insurance
• FSA or HSA
• Paid time off (Vacation, Sick, Personal and Holidays)
• Term Life insurance 
• Short and long-term disability 
• 403B employer contribution 

Why Work at WIHD?

• Positive, inclusive work environment 
• Flexible schedules for work-life balance 
• Mission-driven organization serving 10,000+ individuals annually 

Equal Opportunity Employer

WIHD is committed to fostering a workplace culture that values respect, fairness, and equal opportunity. Employment decisions are based on individual qualifications, experience, and business needs. We comply with all applicable laws and do not discriminate on the basis of race, color, national origin, citizenship status, religion, age, sex, marital status, sexual orientation, gender identity, disability, veteran status, pregnancy, or any other status protected by law.