Chronic Care Management Team Lead

Desert Valley Hospice and Palliative Care • Phoenix, AZ

9h • Hybrid

About The Position

Alliance Medical Clinic and Desert Valley Palliative Care are seeking an experienced, medically knowledgeable, and motivated Chronic Care Management Team Lead to support their primary care, mobile medical, and palliative care programs. The role works closely with the care management coordinator, physicians, nurse practitioners, and interdisciplinary clinical team to oversee daily care management activities, improve patient outcomes, and ensure continuity of care for patients with chronic and complex medical conditions. The ideal candidate has clinical knowledge, organizational and leadership abilities, and experience in chronic disease management, patient education, or care coordination.

This is a hybrid position based primarily from home, with occasional visits to medical offices, assisted living facilities, skilled nursing facilities, and other patient care locations in the Phoenix, Arizona area. The role is offered to an LPN or an experienced medical assistant. Compensation is $24–$26 per hour for a medical assistant, based on experience, or $34 per hour for an LPN.

Requirements

• Active Arizona LPN license or medical assistant training with substantial clinical experience.
• Strong understanding of common medical conditions, medications, and clinical terminology.
• Prior experience in primary care, internal medicine, chronic care management, population health, or a related clinical setting.
• Strong critical-thinking, communication, and organizational abilities.
• Ability to work independently and help provide leadership to a growing team.
• Proficiency with electronic medical records and computer-based workflows.
• Ability to make occasional visits to medical offices and healthcare facilities.

Nice To Haves

• Experience with Medicare CCM, PCM, APCM, or TCM programs.
• Experience in geriatrics, palliative care, home health, or skilled nursing.
• Understanding of HEDIS, Medicare Advantage quality measures, and gaps in care.
• Experience with patient caseload management and quality improvement.
• Previous team lead or supervisory experience.

Responsibilities

• Help lead daily Chronic Care Management activities and support the care management team.
• Collaborate with the care management coordinator on workflows, patient follow-up, and timely documentation.
• Monitor patient outreach, care plan completion, and program performance.
• Assist with staff education, workflow improvements, and quality assurance.
• Identify opportunities to improve patient engagement, operational efficiency, and care management outcomes.
• Serve as a clinical resource within the limits of professional training and licensure.
• Support ongoing management of patients with chronic illnesses, including diabetes, hypertension, congestive heart failure, COPD, coronary artery disease, and dementia.
• Review patient medical histories, medications, and treatment plans.
• Conduct regular telephone outreach and follow-up to monitor patient needs.
• Identify changes in patient status and escalate concerns to appropriate providers.
• Assist with care plan development, implementation, and follow-up.
• Coordinate appointments, referrals, diagnostic testing, and specialty care.
• Support medication reconciliation, adherence, and patient education within scope of practice.
• Identify and help close gaps in care, including preventive screenings, laboratory monitoring, vaccinations, and chronic disease follow-up.
• Support HEDIS, Medicare Advantage, and value-based quality initiatives.
• Coordinate Medicare Annual Wellness Visits and preventive health services.
• Assist with chronic condition documentation and risk adjustment initiatives.
• Track quality outcomes and identify opportunities for improvement.
• Coordinate care for patients discharged from hospitals, rehabilitation centers, and skilled nursing facilities.
• Ensure timely post-discharge outreach and follow-up appointments.
• Review discharge instructions, medication changes, and ongoing care needs.
• Communicate with patients, caregivers, providers, and facilities during transitions of care.
• Help reduce unnecessary emergency department visits and hospital readmissions.
• Support care management for homebound, medically complex, and palliative care patients.
• Collaborate with mobile physicians, nurse practitioners, facility staff, and home health agencies.
• Identify patients who may benefit from additional medical, palliative, or supportive services.
• Participate in occasional facility visits for patient follow-up, education, and care coordination.
• Assist with communication among patients, families, caregivers, and providers.
• Educate patients about chronic illnesses, medication adherence, preventive care, and treatment plans.
• Identify barriers to healthcare, including transportation, financial limitations, medication access, and caregiver support.
• Coordinate community resources and support services.
• Maintain accurate documentation in the electronic medical record.
• Help support CCM, PCM, APCM, and TCM programs.

Benefits

• Competitive compensation based on professional credentials and experience.
• Primarily work-from-home schedule with occasional local travel.
• Opportunity to help lead and expand a growing chronic care management program.
• Collaboration with physicians, nurse practitioners, and an established healthcare team.
• Exposure to primary care, mobile medical services, palliative care, and population health.
• Opportunities for professional growth and additional leadership responsibilities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed