Chronic Care Manager

Chronic Care Manager (CCM)

Marshall Health Network is seeking a compassionate and organized Chronic Care Manager to join our team. In this role, you'll work closely with patients, providers, and caregivers to improve the health outcomes of individuals living with chronic conditions such as diabetes, heart disease, hypertension, and COPD. Your efforts will directly support our mission of Advancing Health, Inspiring Hope, and Serving You by providing proactive, coordinated care.

Key Responsibilities

Patient Care Coordination

• Develop and manage individualized care plans for patients with chronic conditions.
• Monitor patient progress and adherence to treatment plans.
• Educate patients on disease management, medications, lifestyle changes, and preventive care.
• Facilitate communication between primary care providers, specialists, and patients.
• Identify and help address barriers to care, including social and logistical challenges.

Care Management & Support

• Conduct follow-up visits (phone, telehealth, or in-person).
• Support medication adherence and reconciliation.
• Coordinate care transitions (e.g., hospital to home).
• Help patients set and track realistic health goals.

Documentation & Compliance

• Maintain thorough, timely records in the electronic health record (EHR) system.
• Ensure compliance with Medicare CCM program requirements (if applicable).
• Document assessments, interventions, and progress accurately.
• Contribute to quality improvement and performance metrics.

Collaboration & Development

• Participate in interdisciplinary care meetings.
• Share expertise and support training initiatives for team members.
• Stay current with chronic care management best practices.