CCM CHRONIC CARE MANAGEMENT MA

Desert Ridge Family Physicians•Phoenix, AZ

5d•$19 - $22

About The Position

This role focuses on Chronic Care Management (CCM) and Transitional Care Management (TCM) patients. The primary goal is to ensure timely outreach, documentation, and completion of all required program elements for a panel of patients. The position involves direct patient interaction, including outreach, follow-ups, and education to support chronic disease management. Key responsibilities include medication reconciliation, assisting with referrals, coordinating care, and helping patients navigate appointments, labs, imaging, and community resources. All care management activities must be accurately documented in the EHR. The role also emphasizes care coordination and team collaboration, working closely with physicians, supervisors, and clinical staff to support patient care plans. Adherence to established CCM and TCM workflows is crucial for consistency and compliance. The position requires escalating concerns, barriers, or process improvement ideas through leadership channels and participating in team meetings and ongoing training.

Requirements

Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role.
Patient centered and Team oriented
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.
This role requires strong time management, attention to detail, and the ability to work within established processes.

Nice To Haves

Medical Assistant experience preferred.
Experience with Athena EHR or similar systems preferred.

Responsibilities

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.