Medical Assistant or CNA– Chronic Care Management (CCM)

Vellum Health • Houston, TX

1d • $17 - $25

About The Position

We are seeking a compassionate, detail-oriented Medical Assistant (MA) or Certified Nursing Assistant (CNA) to join our unique Chronic Care Management (CCM) team. In this role, you will be our first line of contact for our patients in the CCM program. You will assist our physicians and nurse practitioners but also be available to assist the LTC staff should our patients need minimal care. This is a trendsetting position in LTC facilities that will open the doors to supporting patients with chronic illnesses by providing outreach, care coordination, education, and administrative support that enhances patient outcomes and strengthens continuity of care. This position is ideal for an MA or CNA who enjoys building relationships, helping patients and their families navigate their health conditions, and working as part of an interdisciplinary care team. If you are looking to gain new skills that would put you above the rest in your field, as well as an opportunity to grow within our practice, we would love the opportunity to speak with you. Vellum Health is the first & only platform for on-demand IV enablement & treatment intentionally designed to optimize value for everyone—provider organizations, payers, clinicians, and patients. We believe the future of patient-centered care is shifting beyond the hospital walls—delivering equally positive outcomes at lower cost across the entire healthcare ecosystem. It’s this commitment to redefining where and how care happens that drives us every day.

Requirements

• Certified Medical Assistant (CMA/RMA) or Certified Nursing Assistant (CNA) or equivalent experience
• Prior experience in skilled nursing facilities, LTC facilities, primary care, outpatient clinics, care coordination, or chronic disease management preferred
• Strong communication skills (phone-based care required)
• Ability to work collaboratively with RNs, providers, and care coordinators
• Comfortable using EHR systems and care management software
• Detail-oriented with excellent documentation skills
• Empathy, patience, and strong customer service mindset

Nice To Haves

• Experience with CCM, PCM, RPM, or value-based care programs
• Knowledge of chronic conditions such as diabetes, hypertension, COPD, CHF, CKD, or behavioral health
• Bilingual abilities (Spanish preferred, but not required)
• Familiarity with LTC or SNF patient populations
• Ability to multitask in a fast-paced, mission-driven environment

Responsibilities

• Patient Outreach & Support Make monthly outreach calls to patients enrolled in CCM Assist patients in understanding their chronic conditions, treatment plans, and lifestyle recommendations Review medication adherence and barriers to care Gather updates on symptoms, vitals, and health status
• Care Coordination Communicate with PCPs, specialists, pharmacies, and clinical staff Assist with scheduling follow-up appointments, referrals, and preventive services Document patient interactions accurately in the EHR Relay clinical concerns to the supervising RN or provider promptly
• Care Plan & Documentation Support the creation and updating of individualized care plans Track monthly CCM time to meet CMS billing guidelines Document non–face-to-face care activities clearly and professionally Enter lab updates, RPM data, and health assessments as needed
• Monitoring & Education Provide patient education on chronic conditions such as diabetes, hypertension, CHF, COPD, and depression Identify social determinants of health and connect patients to resources Participate in team meetings to discuss patient progress and needs

Benefits

• Opportunity to make a meaningful difference in the lives of chronically ill patients
• Contribute directly to reducing hospitalizations and improving long-term outcomes
• Growth opportunities within a developing CCM program
• Supportive leadership and interdisciplinary teamwork
• Training provided for CCM workflows, documentation, and CMS requirements

What This Job Offers

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