Chronic Care Management Coordinator (LPN or MA)

About the role

We are seeking an experienced skilled clinical Care Coordinator to join our Chronic Care Management (CCM) program. This is a fast-paced, patient-centered role that requires strong communication skills, excellent organization, and the ability to manage multiple priorities across several patients each day. This role is ideal for a clinician who thrives in proactive care coordination, complex chronic disease management, and patient outreach.

Responsibilities

• CCM Patient Outreach
  • Conduct scheduled Chronic Care Management calls with assigned patients
  • Review patient charts prior to each call to identify care gaps and outstanding needs
  • Follow up on appointments, referrals, labs, imaging, and provider recommendations
• Care Coordination
  • Aid patients in scheduling appointments during outreach calls when possible
  • Track missed, overdue, or pending healthcare services
  • Coordinate with providers, specialists, and internal care teams
  • Ensure continuity of care following hospital or emergency visits
• Medication & Treatment Support
  • Review medication lists for updates or discrepancies
  • Identify refill needs and coordinate with providers
  • Document medication-related concerns and patient adherence issues
• Documentation & Compliance
  • Accurately document all CCM encounters in the EMR
  • Ensure notes are patient-specific, detailed, and reflect actions taken
  • Track all follow-up items until resolution
  • Maintain compliance with CCM program requirements
• Pre-Call Preparation (Required)
  • Review provider notes, orders, and patient history prior to each call
  • Identify overdue appointments, referrals, and diagnostic tests
  • Confirm chart accuracy and care plan status before outreach

Qualifications

• Education, Licensure, Certification: Active licensure, registration, or certification in a related healthcare field (such as Nursing or Certified Clinical Medical Assistant) is required and must be maintained in good standing.
• Experience and Knowledge: 2+ years of experience in a healthcare or administrative clinical setting
• 2+ Experience with medical scheduling, referrals, or patient coordination
• Working knowledge with electronic medical records (EMR) systems
• Strong attention to detail and documentation accuracy
• Excellent communication skills (written, phone, email, and patient-facing interaction)
• Ability to work independently while following structured workflows
• Strong clinical judgment, chart review skills, and EMR proficiency
• Ability to manage high-volume patient panels independently

Preferred Qualifications

• Experience in Chronic Care Management (CCM) or care coordination
• Experience working with patients with chronic conditions or complex care needs
• Knowledge of medical terminology and healthcare workflows
• Experience with insurance, referrals, or prior authorizations

Benefits

• Medical and Dental Insurance
• FSA or HSA
• Paid time off (Vacation, Sick, Personal and Holidays)
• Term Life insurance
• Short and long-term disability
• 403B employer contribution

Why Work at WIHD?

• Positive, inclusive work environment
• Flexible schedules for work-life balance
• Mission-driven organization serving 10,000+ individuals annually
• Equal Opportunity Employer