Chronic Care Management Coordinator

Digestive Disease Consultants
Altamonte Springs, FL

Overview:
We are seeking a Licensed Practical Nurse (LPN) or experienced Medical Assistant (MA) to oversee our Chronic Care Management (CCM) program. The LPN/MA will coordinate care for patients with chronic conditions, ensuring high-quality support, compliance with CMS guidelines, and improved patient outcomes.

Key Responsibilities:

  • Conduct monthly outreach calls to assigned patients.
  • Monitor and record patient-reported symptoms, medication adherence, and barriers to care.
  • Reinforce patient self-management goals as outlined in the care plan.
  • Coordinate referrals, appointments, labs, and testing.
  • Collaborate with providers, specialists, and support services.
  • Identify and escalate clinical concerns to the provider.
  • Review current medications with patient.
  • Maintain accurate documentation and ensure billing compliance.

Qualifications and Skills:

  • Current LPN license, active and in good standing.
  • 2+ years’ clinical experience (chronic disease preferred).
  • Strong communication and patient education skills.
  • Proficient in EHR systems and documentation. ECW experience a plus but not required.
  • Ability to work independently while following clinical protocols
  • Patient-centered, organized, detail-oriented, collaborative, and compassionate.

Work Conditions:

  • Work is performed in an office work environment.
  • Very limited physical effort is required.
  • Limited exposure to physical risk.
Posted 2026-01-08

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