Chronic Care Manager: Patient Outreach & Coordination

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

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.