Chronic Care Coordination Specialist

Desert Ridge Family Physicians; Phoenix (AZ); On-site; USD 46,000 - 62,000; Full time

Benefits offered by this job

401(k) matching

Competitive salary

Dental insurance

Health insurance

Vision insurance

Job summary

Desert Ridge Family Physicians is seeking a care coordination-focused professional to support Chronic Care Management (CCM) and Transitional Case Management (TCM). You will conduct outreach, education, and coordination to improve chronic disease outcomes, while ensuring accurate documentation in the EHR.

The role emphasizes teamwork, adherence to structured workflows, and proactive communication with leadership to address patient needs and workflow challenges.

Qualifications

• Experience 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.
• Ability to follow structured workflows with strong attention to detail.

Responsibilities

• Manage a panel of CCM and TCM patients with timely outreach and documentation.
• Conduct patient outreach, follow-ups, and education to support chronic disease management.
• Assist with medication reconciliation, referrals, and care coordination.
• Help patients navigate appointments, labs, imaging, and community resources.
• Document all care management activities accurately in the EHR.
• Provide care management including phone-based outreach and in-office support as needed.
• Work closely with physicians and clinical staff to support care plans.
• Follow CCM and TCM workflows to ensure consistency and compliance.

Skills

Chronic care management

Care coordination

Team collaboration

Medical Assistant experience

Attention to detail

Time management

Clear communication with leadership

Education

Experience as Medical Assistant

Tools

Athena EHR

Job description

Desert Ridge Family Physicians is seeking a care coordination-focused professional to support Chronic Care Management (CCM) and Transitional Case Management (TCM). You will conduct outreach, education, and coordination to improve chronic disease outcomes, while ensuring accurate documentation in the EHR.

The role emphasizes teamwork, adherence to structured workflows, and proactive communication with leadership to address patient needs and workflow challenges.