Chronic Care Management Coordinator

Digestive Disease Consultants; Florida; On-site; USD 50,000 - 70,000; Full time

Job summary

Digestive Disease Consultants is looking for a Licensed Practical Nurse (LPN) or experienced Medical Assistant (MA) in Florida to oversee their Chronic Care Management program. This role involves conducting monthly patient outreach, monitoring symptoms, coordinating referrals, and collaborating with healthcare providers. The ideal candidate should have an active LPN license, clinical experience, and strong communication skills. The position requires working in an office environment with limited physical effort.

Qualifications

• Current LPN license, active and in good standing.
• 2+ years of clinical experience, preferably in chronic disease.
• Strong communication and patient education skills.
• Proficient in EHR systems; ECW experience is a plus.
• Ability to work independently while following clinical protocols.

Responsibilities

• Conduct monthly outreach calls to assigned patients.
• Monitor and record patient-reported symptoms and medication adherence.
• Reinforce patient self-management goals outlined in the care plan.
• Coordinate referrals, appointments, labs, and testing.
• Collaborate with providers, specialists, and support services.

Skills

Clinical experience

Communication skills

Patient education skills

EHR systems proficiency

Detail-oriented

Education

Current LPN license

Job description

Overview

We are seeking a Licensed Practical Nurse (LPN) or experienced Medical Assistant (MA) to oversee our Chronic Care Management (CCM) program. The LPN/MA will coordinate care for patients with chronic conditions, ensuring high‑quality support, compliance with CMS guidelines, and improved patient outcomes.

Key Responsibilities

• Conduct monthly outreach calls to assigned patients.
• Monitor and record patient‑reported symptoms, medication adherence, and barriers to care.
• Reinforce patient self‑management goals as outlined in the care plan.
• Coordinate referrals, appointments, labs, and testing.
• Collaborate with providers, specialists, and support services.
• Identify and escalate clinical concerns to the provider.
• Review current medications with patient.
• Maintain accurate documentation and ensure billing compliance.

Qualifications and Skills

• Current LPN license, active and in good standing.
• 2+ years’ clinical experience (chronic disease preferred).
• Strong communication and patient education skills.
• Proficient in EHR systems and documentation. ECW experience a plus but not required.
• Ability to work independently while following clinical protocols.
• Patient‑centered, organized, detail‑oriented, collaborative, and compassionate.

Work Conditions

• Work is performed in an office work environment.
• Very limited physical effort is required.
• Limited exposure to physical risk.