Chronic Care Management (CCM) Coordinator

Robert-C.-Byrd-Clinic-1; Lewisburg (WV); On-site; USD 55,000 - 85,000; Full time

Benefits offered by this job

Health benefits

Paid time off

PSLF eligibility

On-campus gym facility

Team-based environment

Work-life balance

Job summary

WVSOM Health seeks a Chronic Care Management (CCM) Coordinator to manage chronic care patients and coordinate care with providers, ensuring CMS billing compliance and high-quality patient outcomes.

The role emphasizes advocacy, resource assistance, and collaboration across the care team to close care gaps and support value-based care programs.

Qualifications

• Knowledge of the regulatory guidelines for Chronic Care Management as outlined by CMS.
• Knowledge of Patient-Centered Medical Home model/mission.
• Experience with health insurance practices and requirements.
• Knowledge and understanding of chronic disease and preventative care measures and their impact on patient health and well-being.
• Good judgement and critical thinking skills are critical.

Responsibilities

• Manage a caseload of an assigned panel of chronic care patients.
• Act as the point of contact for CCM patients regarding all care needs.
• Collaborate with providers to identify appropriate patients for care management.
• Develop relationships with patients as integral members of the care team.
• Provide follow-up management to ensure compliance with care plans.
• Schedule appointments accurately in the EHR.
• Coordinate documentation and pre-visit planning for patient visits.

Skills

CMS guidelines

Patient communication

Critical thinking

Attention to detail

Team collaboration

EHR proficiency

Education

Registered Nurse licensure

Tools

Microsoft Office

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Chronic Care Management (CCM) Coordinator

Full Time Salary Lewisburg, WV, US

WVSOM Health is expanding our care coordination team and seeking a full-time Chronic Care Management (CCM) Coordinator.

Position Purpose:

The Chronic Care Management (CCM) Coordinator role is responsible for managing all aspects of a patient’s healthcare maintenance and treatment and working collaboratively with the patient and other healthcare professionals to ensure seamless, organized, effective, quality care. The primary role of the CCM Coordinator is to be the patient’s advocate in all aspects of their healthcare journey and is instrumental in assisting them with obtaining appropriate resources, as needed.

This role is also responsible to assist the clinic in achieving value-based care goals through multiple insurance quality programs, the Accountable Care Organization (ACO) and the Centers for Medicaid and Medicare Services (CMS). Reviewing and closing care gaps and performing both Chronic Care Management (CCM) and Transitional Care Management (TCM) with CMS patients are important tasks to both the interest of the patient and clinic. This role will develop processes that support these care coordination efforts. Ensure all CMS regulations are met in order to bill and receive reimbursements that support these programs for continued growth.

Position Qualifications:

• Knowledge of the regulatory guidelines for Chronic Care Management as outlined by CMS.
• Knowledge of Patient-Centered Medical Home model/mission.
• Experience with health insurance practices and requirements.
• Knowledge and understanding of chronic disease and preventative care measures and their impact on patient health and well-being.
• Good judgement and critical thinking skills are critical.
• Ability to establish and maintain a good rapport with patients, families, medical staff, and coworkers.
• Excellent written and verbal communication skills.
• Strong attention to detail.
• Ability to prioritize and be willing to invest in a change process to improve effectiveness.
• Able to prioritize and work with little supervision.
• Proficient computer skills, including Microsoft Office, and ability to utilize electronic health record.

Experience:

• A minimum of three years’ experience in a clinical setting

Position Purpose:

The Chronic Care Management (CCM) Coordinator role is responsible for managing all aspects of a patient’s healthcare maintenance and treatment and working collaboratively with the patient and other healthcare professionals to ensure seamless, organized, effective, quality care. The primary role of the CCM Coordinator is to be the patient’s advocate in all aspects of their healthcare journey and is instrumental in assisting them with obtaining appropriate resources, as needed.

This role is also responsible to assist the clinic in achieving value-based care goals through multiple insurance quality programs, the Accountable Care Organization (ACO) and the Centers for Medicaid and Medicare Services (CMS). Reviewing and closing care gaps and performing both Chronic Care Management (CCM) and Transitional Care Management (TCM) with CMS patients are important tasks to both the interest of the patient and clinic. This role will develop processes that support these care coordination efforts. Ensure all CMS regulations are met in order to bill and receive reimbursements that support these programs for continued growth.

Position Qualifications:

• Knowledge of the regulatory guidelines for Chronic Care Management as outlined by CMS.
• Knowledge of Patient-Centered Medical Home model/mission.
• Experience with health insurance practices and requirements.
• Knowledge and understanding of chronic disease and preventative care measures and their impact on patient health and well-being.
• Good judgement and critical thinking skills are critical.
• Ability to establish and maintain a good rapport with patients, families, medical staff, and coworkers.
• Excellent written and verbal communication skills.
• Strong attention to detail.
• Ability to prioritize and be willing to invest in a change process to improve effectiveness.
• Able to prioritize and work with little supervision.
• Proficient computer skills, including Microsoft Office, and ability to utilize electronic health record.

Experience:

• A minimum of three years’ experience in a clinical setting

Licenses/Certifications:

• WV licensure as a Registered Nurse.
• Current BLS Certification.

Job Responsibilities:

• Manage a caseload of an assigned panel of chronic care patients.
• Becomes the point of contact for CCM Patients regarding all care needs (i.e., medication refills, scheduling appointments, answering questions, etc.).
• Collaborate with providers in identifying appropriate patients for care management.
• Develop relationships with patients as an integral member of the care team; always shows compassionate and empathetic care to all clinic patients.
• Provide follow-up management with patients to ensure compliance with their individual care plan.
• Schedule appointments accurately in EHR.
• Anticipate the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed, or medical records are requested, if applicable, before patient visits.
• Promote patient self-management and empower patient to achieve maximum level of wellness and independence.
• Determine and coordinate appropriate referrals as needed.
• Work with patient and patient’s care team to coordinate change readiness, needs assessment, and to develop an individualized treatment care plan.
• Collaborate with the patient, provider, and other care team members in assessing the patient’s progress toward individual health care goals.
• Maintain accessible, consistent documentation of patient self-management measures and progress toward goals using the EHR to allow for proper billing.
• Support patient self-management of disease and behavior modification interventions.
• Assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
• Promote collaborative teamwork and work with peers in a team situation.
• Collaborate with payer Case Managers for additional services when appropriate.
• Develop relationships with medical supply and community resources available to patients.
• Provide follow-up in the transition of care from various settings (hospital or skilled nursing facility discharges and ER visits).
• Coordinate efforts with Care Coordination to achieve goals/metrics for patient care with various insurance companies and the ACO.
• Properly bill for services using appropriate CPT codes.
• Monitors time spent with each patient closely to ensure maximum benefit to the patient.
• Participate in committees as applicable.
• Other duties as assigned.

All employees must comply with WVSOM Health’s excellent customer service standards.

Benefits:

• Comprehensive benefits package including health, dental, vision, life insurance, employer paid long-term disability, retirement savings and match plan
• Paid vacation, sick leave, and holidays
• Qualifying employment for the Public Service Loan Forgiveness (PSLF) Program
• On-campus workout facility that features a regulation basketball court, cardiovascular machines, resistance machines, weights, lockers, and shower facilities
• Collegial team-based work environment
• Opportunity for a balanced professional and personal life

Disclaimer:

Job descriptions are not intended and do not create employment contracts. WVSOM Health maintains its status as an at-will employer. Employees can be terminated for any reason not prohibited by law. All job descriptions have been reviewed in an attempt to illustrate the jobs functions and basic duties, in addition to ‘peripheral tasks’ or that could generally be considered ‘other duties as assigned.’ In no instance, however, should the duties, responsibilities and requirements be interpreted as all-inclusive. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Requirements, experiences, qualifications, knowledge, skills and abilities have been determined to illustrate the minimal standards required to successfully perform the position.

WVSOM Health, located in historic Lewisburg, WV, offers Quality Healthcare...Close to Home.

We are located on the campus of the West Virginia School of Osteopathic Medicine (WVSOM). As a comprehensive not-for-profit health care organization, we are committed to providing quality primary health care to the residents of the greater Greenbrier Valley and surrounding areas. In addition to serving the local communities, WVSOM Health serves as a primary clinical training site for WVSOM students, interns, and residents. We offer a wide range of primary care services, including medical acupuncture, diabetic education, acute care, family medicine, psychology, internal medicine, osteopathic manipulative medicine, pediatric medicine, proctology, mental health, and radiology.

Employment at WVSOM Health is contingent upon the timely and successful completion of a post-offer drug screen, U.S. Citizenship and Immigration Service’s I-9 form, and background investigation including but not limited to whether you have been sanctioned or excluded from participating in any Medicare, Medicaid, or other government-funded programs. WVSOM Health is an Equal Opportunity Employer.