CCM Specialist

Pennant Services

2d•Remote

About The Position

At The Pennant Group, our culture is rooted in CAPLICO—Customer Second, Accountability, Passion for Learning, Love One Another, Intelligent Risk‑Taking, Celebration, and Ownership. We look for leaders who embody these values and elevate them through their work, their teams, and the employee experience. Key Responsibilities Care Coordination and Chronic Care Management (CCM): Develop, implement, and monitor care coordination and CCM workflows and protocols in alignment with CMS guidelines. Promote accurate documentation and monitor billing compliance for CCM services. Educate clinical staff to conduct comprehensive assessments and maintain individualized care plans for patients with chronic conditions. Transitional Care Management (TCM): Participate in the development, implementation, and monitoring of TCM program operations to ensure timely post-discharge follow-up and compliance with CMS requirements. Educate clinical staff on coordination of care during transitions from hospital or skilled nursing facilities to home, reducing readmission risk. Care Continuum Innovation: Participate in the design and implementation of innovative care models that enhance coordination across inpatient, home health, and community settings. Participate in the development of protocols for smooth transitions between levels of care, reducing gaps and improving patient outcomes. Demonstrate knowledge of ACO operations and value-based care strategies, fostering alignment between care coordination workflows, provider partners, and population health goals. Clinical Leadership & Quality Improvement: Serve as the primary point of contact for CCM and care coordination-related inquiries and education for clinical staff and program leaders. Oversee the onboarding process for new MA / care coordinators. Provide ongoing training for clinical team members on best practices for care coordination. Track and report key performance indicators (KPIs) for program effectiveness. Identify opportunities for process improvement and implement evidence-based strategies. Analyze patient outcomes, readmission rates, and utilization data to identify opportunities for improvement. Use evidence-based practices to refine workflows and introduce new technologies or telehealth solutions. Train staff on new processes and technologies, fostering a culture of continuous improvement. The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Requirements

Culture is rooted in CAPLICO—Customer Second, Accountability, Passion for Learning, Love One Another, Intelligent Risk‑Taking, Celebration, and Ownership.
Embody CAPLICO values and elevate them through their work, their teams, and the employee experience.
Knowledge of ACO operations and value-based care strategies.

Nice To Haves

CCM and care coordination workflows and protocols in alignment with CMS guidelines.
TCM program operations to ensure timely post-discharge follow-up and compliance with CMS requirements.
Innovative care models that enhance coordination across inpatient, home health, and community settings.
Protocols for smooth transitions between levels of care, reducing gaps and improving patient outcomes.
Alignment between care coordination workflows, provider partners, and population health goals.
Onboarding process for new MA / care coordinators.
Best practices for care coordination.
Key performance indicators (KPIs) for program effectiveness.
Evidence-based strategies for process improvement.
Patient outcomes, readmission rates, and utilization data analysis.
Evidence-based practices to refine workflows.
New technologies or telehealth solutions.
New processes and technologies training.

Responsibilities

Develop, implement, and monitor care coordination and CCM workflows and protocols in alignment with CMS guidelines.
Promote accurate documentation and monitor billing compliance for CCM services.
Educate clinical staff to conduct comprehensive assessments and maintain individualized care plans for patients with chronic conditions.
Participate in the development, implementation, and monitoring of TCM program operations to ensure timely post-discharge follow-up and compliance with CMS requirements.
Educate clinical staff on coordination of care during transitions from hospital or skilled nursing facilities to home, reducing readmission risk.
Participate in the design and implementation of innovative care models that enhance coordination across inpatient, home health, and community settings.
Participate in the development of protocols for smooth transitions between levels of care, reducing gaps and improving patient outcomes.
Demonstrate knowledge of ACO operations and value-based care strategies, fostering alignment between care coordination workflows, provider partners, and population health goals.
Serve as the primary point of contact for CCM and care coordination-related inquiries and education for clinical staff and program leaders.
Oversee the onboarding process for new MA / care coordinators.
Provide ongoing training for clinical team members on best practices for care coordination.
Track and report key performance indicators (KPIs) for program effectiveness.
Identify opportunities for process improvement and implement evidence-based strategies.
Analyze patient outcomes, readmission rates, and utilization data to identify opportunities for improvement.
Use evidence-based practices to refine workflows and introduce new technologies or telehealth solutions.
Train staff on new processes and technologies, fostering a culture of continuous improvement.