Medical Assistant CCM Chronic Care Coordinator

Desert Ridge Family Physicians • Phoenix, AZ

6d • $24 - $26

About The Position

The Medical Assistant CCM Chronic Care Coordinator manages a panel of Chronic Care Management (CCM) and Transitional Care Management (TCM) patients, ensuring timely outreach, documentation, and completion of required program elements. The role supports chronic disease management through patient outreach, follow-ups, education, medication reconciliation, referrals, and care coordination. It also helps patients navigate appointments, labs, imaging, and community resources.

The coordinator documents care management activities accurately in the EHR and provides support through phone-based outreach and in-office patient assistance as needed. The role works closely with physicians, supervisors, and clinical staff to support patient care plans, follows established CCM and TCM workflows, escalates concerns and barriers through leadership channels, and participates in team meetings and ongoing training. Strong time management, attention to detail, and the ability to work within established processes are essential.

Requirements

• Experience in care coordination, chronic care management, or a similar patient-facing healthcare role.
• Patient-centered and team-oriented approach.
• Organized, dependable, and able to work independently within defined workflows.
• Ability to follow structured workflows with attention to detail and accountability for assigned tasks.
• Ability to understand role responsibilities and maintain professional boundaries within a team-based care model.
• Ability to manage a high-volume workload, prioritize tasks, and meet deadlines in a fast-paced environment.
• Clear, proactive communication with leadership about patient needs, barriers, and workflow concerns.
• Openness to feedback, coaching, and professional development.
• Strong time management and attention to detail.

Nice To Haves

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

Responsibilities

• Manage a panel of CCM and TCM patients and ensure 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.
• Help patients navigate appointments, labs, imaging, and community resources.
• Document care management activities accurately and consistently in the EHR.
• Provide phone-based care management and in-office patient support as needed.
• Work with physicians, supervisors, and clinical staff to support patient care plans.
• Follow established CCM and TCM workflows to promote consistency and compliance.
• Escalate concerns, barriers, and process improvement ideas through leadership channels.
• Participate in team meetings and ongoing training.

Benefits

• 401(k) matching, with a 4% match after six months.
• Medical, dental, and vision insurance; medical benefits are paid 100% for the employee.
• Competitive salary.
• Paid time off (PTO).

What This Job Offers

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