Chronic Care Management

CF Outsourcing Solution is dedicated to providing patients with comprehensive and integrated
healthcare services, with a special focus on behavioral health. Our organization is committed to
delivering accessible, patient-centered care across multiple convenient locations. We strive to
improve health outcomes through innovative care coordination, compassionate service, and a
collaborative approach to healthcare delivery.

Position Summary

CF Outsourcing Solution is seeking a dedicated and detail-oriented Chronic Care Management
(CCM) Specialist to support patients living with chronic medical and behavioral health
conditions. The CCM Specialist plays a critical role in improving patient outcomes through
proactive care coordination, patient engagement, education, and ongoing management of
individualized care plans.

The ideal candidate will possess experience in healthcare delivery, care coordination, case
management, medical documentation, and chronic disease management. This role requires
strong communication skills, clinical knowledge, and the ability to build meaningful relationships
with patients while ensuring compliance with healthcare regulations and quality standards.

Essential Functions

Patient Care Coordination
● Develop, implement, and maintain individualized patient-centered care plans using CCM
software.
● Conduct patient outreach and maintain regular contact to monitor health status,
coordinate care, and provide ongoing support.
● Assist patients in understanding and managing chronic medical and behavioral health
conditions.
● Coordinate healthcare services and referrals to ensure continuity of care.
● Identify barriers to treatment adherence and collaborate with patients and providers to
address care gaps.
● Communicate urgent or life-threatening concerns promptly to Psychiatric Clinicians/Pain
Management Providers and appropriate healthcare providers.

Care Management & Clinical Support

● Manage a caseload of up to 500 enrolled members.
● Conduct patient intake assessments and evaluate healthcare needs.
● Coordinate discharge planning and post-acute care services when appropriate.
● Review patient charts, medications, treatment plans, and referrals to support
comprehensive care management.
● Collaborate with providers, social workers, behavioral health professionals, and other
interdisciplinary team members to optimize patient outcomes.
● Coordinate with scheduling teams to ensure patients attend required appointments and
follow-up visits.
Documentation & Compliance
● Accurately document all patient interactions, care management activities, and treatment
progress within electronic health record systems.
● Maintain detailed and timely records in accordance with organizational policies and
HIPAA regulations.
● Ensure accurate use of medical terminology, CPT coding, ICD-9, and ICD-10 coding for
documentation and billing purposes.
● Monitor member eligibility and qualify patients for monthly CCM billing requirements.
● Add eligible members to billing systems and ensure documentation supports
reimbursement standards.
● Maintain confidentiality and compliance with all federal, state, and organizational
healthcare regulations.
Patient Engagement & Education
● Educate patients regarding their conditions, medications, treatment plans, and available
healthcare resources.
● Promote active participation in care management programs and encourage adherence
to treatment recommendations.
● Build trusting relationships with patients through compassionate communication and
patient-centered service.
● Address patient concerns and provide solutions that support positive healthcare
outcomes.

Duties and Responsibilities

● Coordinate and monitor ongoing care for patients with chronic conditions.
● Develop and update individualized care plans.
● Manage referrals and facilitate communication between healthcare providers.
● Review medications and treatment plans as needed.
● Conduct patient assessments and follow-up activities.

● Support discharge planning and transitions of care.
● Maintain accurate medical records and documentation.
● Ensure timely completion of required CCM activities.
● Meet productivity and quality standards established by CF Outsourcing Solution.
Knowledge, Skills, and Abilities
● Strong oral, written, and telephone communication skills.
● Excellent organizational, multitasking, and time management abilities.
● Knowledge of clinical practices, chronic disease management, diagnostic procedures,
and treatment protocols.
● Understanding of CPT, ICD-9, ICD-10 coding, and medical terminology.
● Strong clinical judgment, critical thinking, and problem-solving skills.
● Ability to work independently and collaboratively in a fast-paced healthcare environment.
● Exceptional customer service and patient engagement skills.
● Ability to build and maintain professional relationships with patients, providers, and
partner organizations.
● Results-driven mindset with a focus on quality outcomes and productivity.

Qualifications

Required Qualifications
● High school diploma or equivalent required.
● Minimum of one (1) year of experience in healthcare, care coordination, case
management, chronic care management, or related healthcare roles.
● Experience working with electronic medical records (EMR/EHR) systems.
● Knowledge of HIPAA regulations and patient confidentiality requirements.
● Strong computer proficiency and documentation skills.
Preferred Qualifications
● Associate's or Bachelor's degree in Healthcare Administration, Nursing, Social Work,
Public Health, or a related field.
● Experience working in hospital, acute care, behavioral health, or outpatient healthcare
settings.
● Familiarity with Chronic Care Management (CCM), Remote Patient Monitoring (RPM), or
value-based care programs.
● Knowledge of discharge planning, care transitions, and behavioral health integration.
● Bilingual abilities are a plus.

Must be able to pass a drug and background check.