Chronic Care Navigator — CCM & TCM Coordinator

Valora Medical Group; Orlando (FL); On-site; USD 52,000 - 65,000; Full time

Job summary

Valora Medical Group in Orlando, FL is seeking a Chronic Care Management (CCM) Coordinator to support patients with chronic conditions by coordinating ongoing care and improving health outcomes.

You will collaborate with providers, clinical staff, patients, caregivers, and community resources to ensure continuity of care, patient engagement, and effective care plan implementation in a value-based care setting.

Qualifications

• Bilingual English/Spanish required.
• CCM, CMS guidelines knowledge.
• Experience with Medicare Advantage and value-based care preferred.
• EMR proficiency and MS Office.

Responsibilities

• Monitor daily hospital admission, discharge, and ED reports to identify patients requiring follow-up.
• Coordinate Transitional Care Management (TCM) services, including outreach, post-discharge scheduling, medication reconciliation, and education.
• Enroll and manage eligible patients in CCM programs per CMS guidelines.
• Develop, implement, and maintain individualized care plans with the care team.
• Educate patients and caregivers on chronic disease management in plain language.
• Encourage medication adherence and preventive care through education and coaching.
• Assess barriers to care and coordinate resources to overcome them.
• Build trusting relationships to improve participation in care plans and long-term disease management.
• Conduct outreach to assess health status, adherence, barriers, and social determinants of health.
• Collaborate with providers, staff, hospitals, and payers to ensure continuity of care.

Skills

Bilingual English/Spanish

Care coordination

Chronic disease management

TCM/CCM knowledge

EMR proficiency

Education

FMG/IMG

LPN

Medical Assistant 5+ years clinical

Tools

EMR systems

Microsoft Office

Job description

Valora Medical Group in Orlando, FL is seeking a Chronic Care Management (CCM) Coordinator to support patients with chronic conditions by coordinating ongoing care and improving health outcomes.

You will collaborate with providers, clinical staff, patients, caregivers, and community resources to ensure continuity of care, patient engagement, and effective care plan implementation in a value-based care setting.