CCM CARE MANAGER – CLINICAL/NON-CLINICAL

Position Summary

The CCM Care Manager provides leadership, coordination, and operational oversight for the Chronic Care Management (CCM) department. This position supports the coordination of patient care management services, patient outreach and engagement, staff productivity, quality initiatives, documentation, and department workflows.

The CCM Care Manager may have a clinical or non-clinical background and will work closely with providers, nurses, LPNs, care coordinators, medical assistants, billing personnel, and administrative staff to ensure effective delivery of CCM services.

Candidates with experience as an LPN, RN, Medical Assistant, Care Coordinator, Healthcare Coordinator, Practice Manager, or healthcare administrative professional are encouraged to apply.

The position requires strong organizational, communication, leadership, and problem-solving skills, as well as the ability to work independently while coordinating multiple patient and departmental needs.

Essential Responsibilities

Department Operations & Leadership

• Oversee daily CCM department operations and workflows.
• Coordinate daily assignments, patient outreach, enrollment, follow-up, and care management activities.
• Monitor work queues, staff productivity, patient engagement, and completion of assigned tasks.
• Identify workflow issues and implement appropriate process improvements.
• Develop, maintain, and update CCM policies, procedures, workflows, and standard operating procedures.
• Serve as a primary liaison between CCM staff, providers, nursing, billing, front office, and other departments.
• Assist with scheduling, workload distribution, and coverage to support department operations.
• Monitor department performance and communicate concerns or opportunities for improvement to leadership.
• Participate in department meetings and provide operational updates.

Patient Outreach & Care Management Support

• Coordinate patient outreach and enrollment activities for eligible CCM patients.
• Support ongoing patient engagement and retention.
• Assist staff with identifying barriers to patient participation and appropriate follow-up.
• Coordinate communication between patients, providers, nursing staff, and other members of the healthcare team.
• Assist with care coordination activities within the scope of the individual's education, licensure, and assigned responsibilities.
• Monitor patient follow-up and completion of assigned CCM activities.
• Assist with identifying patients who may benefit from additional services or provider follow-up.
• Maintain appropriate communication and documentation related to patient outreach and care management activities.

Clinical Support – When Applicable

For candidates who hold an active LPN or RN license, the position may include clinical care management responsibilities within the individual's scope of practice and applicable organizational policies.

Clinical responsibilities may include:

• Reviewing patient information and identifying care management needs.
• Participating in patient assessments and care coordination.
• Providing patient education and health-related resources within scope of practice.
• Monitoring patient-reported concerns and communicating significant findings to the appropriate provider.
• Assisting with medication reconciliation and medication-related communication as permitted by licensure and organizational policy.
• Supporting chronic disease management and patient self-management education.
• Communicating changes in patient condition to providers or other members of the healthcare team.
• Assisting with development, implementation, and follow-up of individualized care management plans.
• Coordinating referrals, appointments, testing, and follow-up services as appropriate.
• Supporting transitional care and follow-up after hospital or facility discharge when assigned.
• Performing other clinical CCM functions consistent with licensure, payer requirements, and organizational policy.

The level of clinical responsibility will be based upon the employee's licensure, qualifications, experience, and applicable scope of practice.

Documentation & Compliance

• Ensure CCM activities are accurately and timely documented in eClinicalWorks (eCW).
• Accurately capture qualifying CCM services and time when applicable.
• Monitor documentation for completeness, accuracy, and compliance with organizational requirements.
• Support appropriate documentation of:
  • Non-face-to-face care management services, when applicable.
  • Contemporaneous documentation.
  • Personally performed services.
  • Medical necessity.
  • Patient participation and engagement.
  • Applicable CMS and payer requirements.
• Assist with internal audits and quality reviews.
• Identify documentation deficiencies and provide coaching or education as needed.
• Maintain patient confidentiality and comply with HIPAA and organizational privacy policies.

Staff Development & Training

• Assist with onboarding and orientation of new CCM employees.
• Provide training related to CCM workflows, documentation, eCW, patient outreach, and departmental procedures.
• Provide ongoing coaching and support to CCM staff.
• Assist employees in understanding productivity and quality expectations.
• Promote teamwork, accountability, professionalism, and effective communication.
• Identify training needs and make recommendations to department leadership.

Quality & Performance Improvement

• Monitor CCM department quality indicators and performance metrics.
• Track patient enrollment, engagement, retention, productivity, and documentation performance.
• Prepare operational reports and performance dashboards.
• Review trends and identify opportunities for improvement.
• Participate in quality improvement initiatives.
• Assist leadership in developing action plans when performance or compliance concerns are identified.
• Monitor progress toward departmental goals.

Qualifications

Required

• High School Diploma or GED required.
• Healthcare experience required.
• Strong organizational and communication skills.
• Ability to manage multiple priorities and work independently.
• Strong computer and electronic health record skills.
• Ability to maintain patient confidentiality and follow HIPAA requirements.

Preferred

Candidates with one or more of the following are encouraged to apply:

• Active Licensed Practical Nurse (LPN/LVN) license.
• Active Registered Nurse (RN) license.
• Medical Assistant certification or experience.
• Associate's or Bachelor's degree in nursing, healthcare administration, health information management, or related field.
• Three or more years of healthcare experience.
• Experience with Chronic Care Management (CCM).
• Experience with Remote Patient Monitoring (RPM).
• Experience with telehealth or care coordination.
• Experience with eClinicalWorks (eCW) or another electronic health record.
• Previous leadership, supervisory, care coordination, or healthcare management experience.

Knowledge, Skills & Abilities

• Knowledge of healthcare operations and patient care coordination.
• Understanding of CCM, RPM, telehealth, and chronic disease management concepts.
• Ability to understand and follow applicable CMS, payer, and organizational requirements.
• Strong attention to detail and documentation skills.
• Excellent verbal and written communication skills.
• Ability to build positive working relationships with patients, providers, nurses, and administrative staff.
• Ability to coach, train, and support team members.
• Strong problem-solving and critical-thinking skills.
• Ability to analyze productivity and quality data.
• Ability to prioritize work in a fast-paced healthcare environment.
• Ability to maintain professionalism and confidentiality at all times.

Success Measures

Success in this position will be measured by:

• CCM department productivity.
• Patient enrollment and retention.
• Patient engagement and outreach completion.
• Documentation accuracy and timeliness.
• Quality and compliance performance.
• Workflow efficiency.
• Staff training and development.
• Effective communication between CCM, clinical, and administrative teams.
• Patient satisfaction and service experience.
• Successful completion of department goals and performance initiatives.

Physical & Work Environment

• Primarily office-based with extensive computer and telephone use.
• May require prolonged sitting and periods of repetitive computer work.
• May require occasional movement throughout the healthcare facility.
• Clinical responsibilities, when applicable, will be performed within the employee's licensure and assigned scope of practice.