Responsible for facilitating care coordination services for Medicare Chronic Care Management (CCM) enrolled patients. The role ensures eligible patients receive timely, high-quality, efficient health care and support services while acting as a guide and advocate for patients and their families.
The Chronic Care Manager works closely with providers, practice managers, clinical staff, and the revenue cycle team to identify eligible patients, support care planning, coordinate referrals, follow up after emergency room visits or hospital discharges, and ensure CCM services are documented and billed accurately.
Key responsibilities include pre-visit planning, identifying CCM-eligible patients, obtaining informed consent, supporting patient self-management, linking patients with community resources, communicating care plans and test results, assisting with patient assistance programs, documenting quality measures, and ensuring compliance with CMS CCM scope of service requirements.
This position also serves as a patient-centered point of contact, helping patients and families navigate the health care system, address social or financial barriers, and access appropriate services and resources.
Qualifications
- Licensed Practical Nurse degree or Medical Assistant certification
- One year of experience or exposure to medical records
- Proficiency in English, including reading, speaking, understanding, and writing
- Strong oral and written communication skills
- Working knowledge of MS Office products and EHR/practice management systems
- Knowledge of HIPAA and corporate compliance requirements
- Ability to work independently and in a team environment
- Strong organizational skills with the ability to prioritize and coordinate multiple tasks
- Ability to remain calm and effective in high-pressure or emergency situations
- Thorough knowledge of community resources and needs-assessment information
- Ability to build and maintain positive relationships with staff, management, providers, community organizations, and the public
Location
Georgia, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
Yes
Posted
1 week ago