Licensed Practical Nurse - CCM

Medical University of South Carolina•Remote- South Carolina, SC

2d•Remote

About The Position

The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) outreach to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient outcomes, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through structured monthly outreach, education, care plan management and promotes patient well-being through timely follow-up, education, and coordination of services.

Requirements

Active LPN licensure in good standing (South Carolina preferred)
BLS (Basic Life Support) certification (if required by role)
Strong communication and interpersonal skills
Ability to assess patient needs and apply clinical judgment appropriately
Proficiency in EHR documentation and care coordination workflows (experience with Epic Systems preferred)
Knowledge of chronic disease management and population health principles
Ability to manage a high-volume patient panel efficiently
Strong organizational and time management skills
Ability to work independently within established workflows and SOPs
Ability to appropriately route communication to providers vs. clinical support teams

Nice To Haves

Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred
Experience working with high-risk or chronic condition populations strongly preferred

Responsibilities

Conduct monthly telephonic outreach to assigned CCM patient panel
Complete a minimum of 20 minutes of non–face-to-face care management services per patient per calendar month
Perform at least two outreach attempts for patients not reached
Assess patient status, including changes in condition, symptoms, or care needs
Review and reinforce individualized care plans and patient goals
Support medication adherence and identify potential medication concerns
Identify and address barriers to care (e.g., transportation, access to medications, social needs)
Assist with scheduling appointments when clinical evaluation is needed
Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards
Document all interactions accurately in the electronic health record (EHR) and track time for billing compliance
Collaborate with providers, care teams, and community resources to ensure continuity of care
Provide education on chronic disease management and preventive care
Encourage patient participation in primary care and adherence to treatment plans
Monitor for signs of deterioration and escalate concerns appropriately
Support transitions of care when applicable
Promote patient self-management and engagement in their health