CCM Specialist (RN)

Key Responsibilities

• Care Coordination and Chronic Care Management (CCM): Develop, implement, and monitor care coordination and CCM workflows and protocols in alignment with CMS guidelines. Promote accurate documentation and monitor billing compliance for CCM services. Educate clinical staff to conduct comprehensive assessments and maintain individualized care plans for patients with chronic conditions.
• Transitional Care Management (TCM): Participate in the development, implementation, and monitoring of TCM program operations to ensure timely post-discharge follow-up and compliance with CMS requirements. Educate clinical staff on coordination of care during transitions from hospital or skilled nursing facilities to home, reducing readmission risk.
• Care Continuum Innovation: Participate in the design and implementation of innovative care models that enhance coordination across inpatient, home health, and community settings. Participate in the development of protocols for smooth transitions between levels of care, reducing gaps and improving patient outcomes.
• Demonstrate knowledge of ACO operations and value-based care strategies, fostering alignment between care coordination workflows, provider partners, and population health goals.
• Clinical Leadership & Quality Improvement: Serve as the primary point of contact for CCM and care coordination-related inquiries and education for clinical staff and program leaders. Oversee the onboarding process for new MA / care coordinators. Provide ongoing training for clinical team members on best practices for care coordination. Track and report key performance indicators (KPIs) for program effectiveness. Identify opportunities for process improvement and implement evidence-based strategies. Analyze patient outcomes, readmission rates, and utilization data to identify opportunities for improvement. Use evidence-based practices to refine workflows and introduce new technologies or telehealth solutions. Train staff on new processes and technologies, fostering a culture of continuous improvement.

About the Role

The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets.

Benefits

Full benefits package: medical, dental, vision, 401(k) with match
Generous PTO, holidays, and professional development

Pay

DOE

Schedule

Full-Time