Chronic Care Management

•  Manage a panel of CCM and TCM patients, ensuring timely outreach, documentation, and completion of required program elements. 
•  Conduct patient outreach, follow-ups, and education to support chronic disease management. 
•  Assist with medication reconciliation, referrals, and care coordination. 
•  Support patients in navigating appointments, labs, imaging, and community resources. 
•  Document all care management activities accurately and consistently in the EHR. 
•  Provide care management, including phone-based outreach and in office patient support as needed. 

•  Work closely with physicians, supervisors, and clinical staff to support patient care plans. 
•  Follow established CCM and TCM workflows to ensure consistency and compliance. 
•  Escalate concerns, barriers, or process improvement ideas through leadership channels. 
•  Participate in team meetings and ongoing training. 

•  Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role. 
• Patient centered and Team oriented
•  Medical Assistant experience preferred . 
•  Organized, dependable, and able to work independently within defined workflows. 
•  Able to follow structured workflows while maintaining strong attention to detail and accountability for assigned tasks. 
•  Understands role responsibilities and maintains appropriate professional boundaries within a team-based care model. 
•  Able to manage a high-volume workload, prioritize tasks effectively, and meet deadlines in a fast-paced environment. 
•  Communicates clearly and proactively with leadership regarding patient needs, barriers, and workflow concerns. 
•  Open to feedback, coaching, and professional development. 
•  Experience with Athena EHR or similar systems preferred. 

•  Supportive leadership with clear expectations, structured workflows, and accountability. 
•  Established systems that allow you to focus on patient care without unnecessary chaos. 
•  Opportunities to build skills in CCM, TCM, and care coordination. 
•  A collaborative environment that values teamwork, consistency, and growth. 
•  Meaningful work that helps reduce hospitalizations and improve patient outcomes.