Chronic Care Management

WC Health•Las Vegas, NV

About The Position

CF Outsourcing Solution is seeking a dedicated and detail-oriented Chronic Care Management (CCM) Specialist to support patients living with chronic medical and behavioral health conditions. The CCM Specialist plays a critical role in improving patient outcomes through proactive care coordination, patient engagement, education, and ongoing management of individualized care plans. The ideal candidate will possess experience in healthcare delivery, care coordination, case management, medical documentation, and chronic disease management. This role requires strong communication skills, clinical knowledge, and the ability to build meaningful relationships with patients while ensuring compliance with healthcare regulations and quality standards.

Requirements

High school diploma or equivalent required.
Minimum of one (1) year of experience in healthcare, care coordination, case management, chronic care management, or related healthcare roles.
Experience working with electronic medical records (EMR/EHR) systems.
Knowledge of HIPAA regulations and patient confidentiality requirements.
Strong computer proficiency and documentation skills.
Strong oral, written, and telephone communication skills.
Excellent organizational, multitasking, and time management abilities.
Knowledge of clinical practices, chronic disease management, diagnostic procedures, and treatment protocols.
Understanding of CPT, ICD-9, ICD-10 coding, and medical terminology.
Strong clinical judgment, critical thinking, and problem-solving skills.
Ability to work independently and collaboratively in a fast-paced healthcare environment.
Exceptional customer service and patient engagement skills.
Ability to build and maintain professional relationships with patients, providers, and partner organizations.
Results-driven mindset with a focus on quality outcomes and productivity.

Nice To Haves

Associate's or Bachelor's degree in Healthcare Administration, Nursing, Social Work, Public Health, or a related field.
Experience working in hospital, acute care, behavioral health, or outpatient healthcare settings.
Familiarity with Chronic Care Management (CCM), Remote Patient Monitoring (RPM), or value-based care programs.
Knowledge of discharge planning, care transitions, and behavioral health integration.
Bilingual abilities are a plus.

Responsibilities

Develop, implement, and maintain individualized patient-centered care plans using CCM software.
Conduct patient outreach and maintain regular contact to monitor health status, coordinate care, and provide ongoing support.
Assist patients in understanding and managing chronic medical and behavioral health conditions.
Coordinate healthcare services and referrals to ensure continuity of care.
Identify barriers to treatment adherence and collaborate with patients and providers to address care gaps.
Communicate urgent or life-threatening concerns promptly to Psychiatric Clinicians/Pain Management Providers and appropriate healthcare providers.
Manage a caseload of up to 500 enrolled members.
Conduct patient intake assessments and evaluate healthcare needs.
Coordinate discharge planning and post-acute care services when appropriate.
Review patient charts, medications, treatment plans, and referrals to support comprehensive care management.
Collaborate with providers, social workers, behavioral health professionals, and other interdisciplinary team members to optimize patient outcomes.
Coordinate with scheduling teams to ensure patients attend required appointments and follow-up visits.
Accurately document all patient interactions, care management activities, and treatment progress within electronic health record systems.
Maintain detailed and timely records in accordance with organizational policies and HIPAA regulations.
Ensure accurate use of medical terminology, CPT coding, ICD-9, and ICD-10 coding for documentation and billing purposes.
Monitor member eligibility and qualify patients for monthly CCM billing requirements.
Add eligible members to billing systems and ensure documentation supports reimbursement standards.
Maintain confidentiality and compliance with all federal, state, and organizational healthcare regulations.
Educate patients regarding their conditions, medications, treatment plans, and available healthcare resources.
Promote active participation in care management programs and encourage adherence to treatment recommendations.
Build trusting relationships with patients through compassionate communication and patient-centered service.
Address patient concerns and provide solutions that support positive healthcare outcomes.
Coordinate and monitor ongoing care for patients with chronic conditions.
Develop and update individualized care plans.
Manage referrals and facilitate communication between healthcare providers.
Review medications and treatment plans as needed.
Conduct patient assessments and follow-up activities.
Support discharge planning and transitions of care.
Maintain accurate medical records and documentation.
Ensure timely completion of required CCM activities.
Meet productivity and quality standards established by CF Outsourcing Solution.