Remote Chronic Care Management (CCM) Coordinator

Ascend Medical Georgia PC•Athens, GA

1d•Remote

About The Position

This role provides telephonic and digital care coordination for patients with multiple chronic conditions. The CCM Coordinator engages patients remotely to support chronic disease management, build individualized care plans, ensure ongoing follow-up, and help close care gaps. The role works closely with primary care providers and care teams to improve outcomes, adherence, and patient experience. Responsibilities align with Medicare CCM standards and documentation requirements.

Requirements

Clinical background (Medical Assistant, LPN, RN) or equivalent experience in care coordination or healthcare support roles.
Experience with chronic disease management, patient education, or care coordination.
Strong communication skills and comfort engaging patients by phone and digital tools.
Ability to work independently in a remote environment with reliable internet access.
Proficiency with electronic health records and care management platforms.

Nice To Haves

Prior experience in Chronic Care Management, Remote Patient Monitoring, or similar population health programs
Knowledge of CMS CCM billing, documentation, and time tracking requirements
Experience working in an electronic medical record (EMR) system, preferably in a primary care or ambulatory setting
Comfort navigating multiple technology platforms while delivering remote patient care
Bilingual skills a plus

Responsibilities

Proactively contact assigned panel of patients to assess health status, medication adherence, barriers to care, and self-management needs.
Educate and coach patients on chronic conditions, preventive care, and care plan goals in collaboration with providers.
Obtain verbal consent and enroll eligible patients into CCM programs.
Develop, update, and maintain individualized care plans based on patient needs and provider direction.
Track and document all interactions, care activities, and care plans in the EHR or care management platform to meet documentation and billing standards.
Coordinate follow-ups, referral tracking, and patient reminders for appointments and preventive services.
Identify social determinants of health and connect patients with appropriate community resources.
Work with primary care providers, nurses, and care teams to share updates and escalate clinical concerns.
Participate in care team meetings and contribute to continuous quality improvement efforts tied to chronic care measures.
Maintain compliance with CMS CCM requirements and organizational protocols.