Chronic Care Management

This role involves managing a panel of patients enrolled in Chronic Care Management (CCM) and Transition Care Management (TCM) programs, ensuring timely outreach, documentation, and completion of required program elements. The position requires conducting patient follow-ups, assisting with medication reconciliation and care coordination, and supporting patients in navigating healthcare resources. The role focuses on maintaining accurate EHR documentation and collaborating with clinical teams to improve patient outcomes and reduce hospitalizations.