MEDICAL ASSISTANT CCM CHRONIC CARE MANAGEMENT

Desert Ridge Family Physicians; Phoenix (AZ); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

401(k) matching

Bonus based on performance

Competitive salary

Dental insurance

Health insurance

Home office stipend

Paid time off

Training & development

Vision insurance

Chronic Care Management

Full medical benefits paid 100% for .

Job summary

Desert Ridge Family Physicians seeks a dedicated Care Coordinator to support Chronic Care Management (CCM) and Transitional Care Management (TCM) programs. You will conduct patient outreach, documentation, and coordination with clinical staff to ensure timely care and enrollment in programs.

Ideal candidates are organized, detail-oriented, and comfortable working with Athena EHR or similar systems. Experience as a Medical Assistant is preferred; strong teamwork and communication are essential.

Qualifications

• Experienced in care coordination or chronic care management.
• Patient-centered and team-oriented.
• Medical Assistant experience preferred.
• Organized, dependable, and able to work independently.
• Able to manage high-volume workload with attention to detail.

Responsibilities

• Manage a panel of CCM and TCM patients, ensuring timely outreach, documentation, and completion of required program elements.
• Conduct patient outreach, follow-ups, and education to support chronic disease management.
• Assist with medication reconciliation, referrals, and care coordination.
• Support patients in navigating appointments, labs, imaging, and community resources.
• Document all care management activities accurately and consistently in the EHR.
• Provide care management, including phone-based outreach and in office patient support as needed.

Skills

Care coordination

Chronic care management

Patient outreach

Documentation in EHR

Teamwork

Education

Medical Assistant experience preferred

Tools

Athena EHR

EHR systems

Job description

Benefits

• 401(k) matching
• Bonus based on performance
• Competitive salary
• Dental insurance
• Health insurance
• Home office stipend
• Paid time off
• Training & development
• Vision insurance
• Chronic Care Management
• Full medical benefits paid 100% for employee 401k with 4% match at 6 months, competitive salary & PTO

Responsibilities

• Manage a panel of CCM and TCM patients, ensuring timely outreach, documentation, and completion of required program elements.
• Conduct patient outreach, follow-ups, and education to support chronic disease management.
• Assist with medication reconciliation, referrals, and care coordination.
• Support patients in navigating appointments, labs, imaging, and community resources.
• Document all care management activities accurately and consistently in the EHR.
• Provide care management, including phone-based outreach and in office patient support as needed.
• Work closely with physicians, supervisors, and clinical staff to support patient care plans.
• Follow established CCM and TCM workflows to ensure consistency and compliance.
• Escalate concerns, barriers, or process improvement ideas through leadership channels.
• Participate in team meetings and ongoing training.

Qualifications

• Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role.
• Patient centered and team oriented.
• Medical Assistant experience preferred.
• Organized, dependable, and able to work independently within defined workflows.
• Able to follow structured workflows while maintaining strong attention to detail and accountability for assigned tasks.
• Understands role responsibilities and maintains appropriate professional boundaries within a team-based care model.
• Able to manage a high-volume workload, prioritize tasks effectively, and meet deadlines in a fast-paced environment.
• Communicates clearly and proactively with leadership regarding patient needs, barriers, and workflow concerns.
• Open to feedback, coaching, and professional development.
• Experience with Athena EHR or similar systems preferred.

Why You'll Love Working Here

• Supportive leadership with clear expectations, structured workflows, and accountability.
• Established systems that allow you to focus on patient care without unnecessary chaos.
• Opportunities to build skills in CCM, TCM, and care coordination.
• A collaborative environment that values teamwork, consistency, and growth.
• Meaningful work that helps reduce hospitalizations and improve patient outcomes.
• This role requires strong time management, attention to detail, and the ability to work within established processes.