What are the responsibilities and job description for the Chronic Care Management (CCM) Coordinator position at Hillside Primary Care?
Position Title: Chronic Care Management (CCM) Coordinator
Department: Population Health & Care Coordination
Reports To: CCM Manager
Location: Onsite – Hillside Medical Group (This is not a remote position)
About Us:
Hillside Medical Group is a leading outpatient primary care organization dedicated to delivering compassionate, high-quality care across Texas. Our team-driven environment supports innovation, collaboration, and continuous improvement in both clinical and administrative healthcare delivery. We are committed to excellence in value-based care, population health, and chronic disease management.
Position Summary
Hillside Medical Group is seeking a detail-oriented and proactive Chronic Care Management (CCM) Coordinator to join our care coordination team. This role is ideal for candidates with prior medical or healthcare experience and a strong understanding of chronic disease management, Medicare quality measures, and care coordination workflows.
The CCM Coordinator is responsible for managing a panel of patients with chronic conditions, maintaining accurate care plans, ensuring compliance with CMS Chronic Care Management requirements, and supporting overall population health initiatives. This position combines clinical knowledge, data management, and administrative oversight to improve patient outcomes across our primary care network.
Key Responsibilities
Chronic Care Management & Coordination
Coordinate all activities under the Medicare Chronic Care Management (CCM) program in accordance with CMS guidelines.
Develop, update, and document individualized care plans for patients with two or more chronic conditions.
Conduct regular phone-based outreach (non-patient-facing) to assess progress, review medications, and reinforce self-management goals.
Accurately document time spent and interventions performed within the EHR system for billing compliance.
Identify care gaps and collaborate with providers, clinical staff, and the Quality team to improve patient outcomes.
Maintain working knowledge of chronic disease processes and treatment protocols (e.g., diabetes, hypertension, COPD, CHF).
Administrative & Quality Support
Track, analyze, and report CCM metrics and performance data for program optimization.
Collaborate with the Population Health and Quality Improvement teams to support value-based care initiatives.
Assist in aligning CCM workflows with Medicare and commercial payer compliance standards.
Support periodic audits and ensure thorough, accurate recordkeeping within CMS and organizational policies.
Qualifications
Minimum Requirements
2–3 years of healthcare experience in a clinical, care coordination, or population health role.
Working knowledge of chronic care management and/or Medicare quality measures.
Familiarity with medical terminology, EHR documentation, and medication management.
Strong written and oral communication skills with the ability to multitask and manage multiple patient cases efficiently.
Excellent attention to detail and accuracy in documentation.
Demonstrated understanding of HIPAA and patient confidentiality standards.
Preferred Qualifications
Previous experience working in a primary care setting or value-based care model.
Prior Chronic Care Management (CCM) or Remote Patient Monitoring (RPM) program experience.
Knowledge of CMS billing codes (99490, 99487, 99489) and compliance requirements.
Bilingual (English/Spanish) preferred.
Experience using population health tools, care coordination platforms, or data dashboards (e.g., MetriX, Lightbeam, Athena, or similar).
Work Schedule & Compensation
Schedule: Full-time, Monday–Friday.
Location: Onsite only; not a remote position.
Compensation: Competitive salary based on experience, with comprehensive benefits including medical, dental, vision, PTO, and 401(k).
Visa Sponsorship
Hillside Medical Group welcomes applications from candidates who require H-1B visa sponsorship. We are an experienced and supportive sponsor of qualified international healthcare professionals.
Equal Opportunity Employer
Hillside Medical Group is proud to be an Equal Employment Opportunity (EEOC) employer. We are committed to fostering a diverse and inclusive environment and make all employment decisions without regard to race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity, veteran status, or any other protected category under applicable federal, state, or local law.
How to Apply
Please submit your resume and a brief cover letter detailing your qualifications and interest in this role to admin@hillsidemedicalgroup.com