Chronic Care Management Program Lead

Sixteenth Street Community Health Center, Inc.; Milwaukee (WI); On-site; USD 70,000 - 90,000; Full time

Job summary

Sixteenth Street Community Health Centers in Milwaukee, WI seeks a Chronic Care Management Program Manager to grow and sustain the Care Coordination Program. You will oversee CCM staff, supervise care plans, and coordinate with clinical teams to improve outcomes.

The role emphasizes recruiting patients, ensuring wellness visits, quality improvement, data analysis from EHR/Registry, and collaboration across departments.

Qualifications

• RN, BSN preferred.
• Chronic Care Management background.
• Experience educating patients and goal setting preferred.
• Supervisory experience preferred.
• Ability to relate to diverse backgrounds.
• Bilingual preferred.
• Proficient with EMR (EPIC) and Compass Rose.
• Maintain HIPAA compliance.
• Customer service oriented.
• Adaptable to change.
• Ability to work under pressure.

Responsibilities

• Grow and maintain the Care Coordination/CCM program and staff.
• Supervise development of care plans and enrollment.
• Recruit and maintain patients enrolled in care management.
• Ensure annual wellness visits and follow-up on preventive plan elements.
• Discuss advance care planning with patients.
• Support care coordination staff and collaborate with interdepartmental teams.
• Render CCM services as needed and represent the program externally.
• Manage staffing per productivity targets; interview, hire, educate, coach, evaluate.
• Analyze clinical data from EHR/Registry and identify gaps in care.
• Provide training to CCM staff on best practices and quality improvement.
• Promote patient quality of life and effective care transitions.
• Coordinate care resources and community referrals.
• Act as liaison with referral sources and facilities to resolve continuum of care issues.
• Communicate with partners to facilitate efficient use of healthcare resources.
• Maintain confidentiality and infection control policies.
• Attend required trainings and meetings; maintain annual competencies.
• Perform other duties as assigned.

Skills

Chronic care

Supervisory experience

Patient education

Bilingual (Spanish/English)

HIPAA compliance

Customer service

EPIC proficiency

Decision making under pressure

Education

RN, BSN preferred

Job description

Sixteenth Street Community Health Centers in Milwaukee, WI seeks a Chronic Care Management Program Manager to grow and sustain the Care Coordination Program. You will oversee CCM staff, supervise care plans, and coordinate with clinical teams to improve outcomes.

The role emphasizes recruiting patients, ensuring wellness visits, quality improvement, data analysis from EHR/Registry, and collaboration across departments.