Licensed Practical Nurse - Chronic Care Management

C018 MUSC Community Physicians (MCP); South Carolina; Hybrid; USD 52,000 - 70,000; Full time

Benefits offered by this job

Health

Dental

Vision

Life insurance

Paid time off

Job summary

Medical University of South Carolina seeks an LPN Care Team Member to lead Chronic Care Management outreach for patients with multiple chronic conditions. You will perform structured monthly outreach, educate patients, manage care plans, and coordinate services to improve outcomes and reduce hospitalizations.

The role emphasizes documentation in the EHR, care plan reinforcement, and timely follow-up. Previous care coordination, ambulatory care, or chronic disease management experience is highly

Qualifications

• Active LPN licensure in good standing (South Carolina preferred).
• BLS (Basic Life Support) certification (if required by role).
• Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred.

Responsibilities

• Conduct monthly telephonic outreach to assigned CCM patient panel.
• Complete a minimum of 20 minutes of non-face-to-face care management services per patient per calendar month.
• Perform at least two outreach attempts for patients not reached.
• Assess patient status, including changes in condition, symptoms, or care needs.
• Review and reinforce individualized care plans and patient goals.
• Support medication adherence and identify potential medication concerns.
• Identify and address barriers to care (e.g., transportation, access to medications, social needs).
• Assist with scheduling appointments when clinical evaluation is needed.
• Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards.
• Document all interactions accurately in the electronic health record (EHR) and track time for billing compliance.
• Collaborate with providers, care teams, and community resources to ensure continuity of care.

Skills

Strong communication

Interpersonal skills

Clinical judgment

Epic Systems

Care coordination

Population health

Time management

Independent work

Routing communications

Education

LPN license

BLS certification

Tools

Epic Systems

Job description

Job Description Summary

The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) outreach to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient outcomes, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through structured monthly outreach, education, care plan management and promotes patient well-being through timely follow-up, education, and coordination of services.

Key Responsibilities

• Conduct monthly telephonic outreach to assigned CCM patient panel
• Complete a minimum of 20 minutes of non-face-to-face care management services per patient per calendar month
• Perform at least two outreach attempts for patients not reached
• Assess patient status, including changes in condition, symptoms, or care needs
• Review and reinforce individualized care plans and patient goals
• Support medication adherence and identify potential medication concerns
• Identify and address barriers to care (e.g., transportation, access to medications, social needs)
• Assist with scheduling appointments when clinical evaluation is needed
• Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards
• Document all interactions accurately in the electronic health record (EHR) and track time for billing compliance
• Collaborate with providers, care teams, and community resources to ensure continuity of care

Care Coordination & Patient Engagement

• Provide education on chronic disease management and preventive care
• Encourage patient participation in primary care and adherence to treatment plans
• Monitor for signs of deterioration and escalation concerns appropriately
• Support transitions of care when applicable
• Promote patient self-management and engagement in their health

Required Skills & Competencies

• Strong communication and interpersonal skills
• Ability to assess patient needs and apply clinical judgment appropriately
• Proficiency in EHR documentation and care coordination workflows (experience with Epic Systems preferred)
• Knowledge of chronic disease management and population health principles
• Ability to manage a high-volume patient panel efficiently
• Strong organizational and time management skills
• Ability to work independently within established workflows and SOPs
• Ability to appropriately route communication to providers vs. clinical support teams

Qualifications

• Active LPN licensure in good standing (South Carolina preferred)
• BLS (Basic Life Support) certification (if required by role)
• Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred
• Experience working with high-risk or chronic condition populations strongly preferred

Benefits:

• Health
• Dental
• Vision
• Life insurance
• Employer Sponsored Retirement Plan
• Paid time off and extended sick leave
• Paid Parental Leave
• Disability insurance plan options
• Continuous professional and clinical training
• Competitive pay
• Annual Merit Increase
• Wellbeing resources
• Tuition Reimbursement
• Employee perks and discounts
• Employee referral program
• Flexible schedule options
• Certification incentive program

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees Thank you for wanting to be part of the Medical University of South Carolina team. Whether you want to teach the next generation of health care leaders, innovate new business models, discover the next breakthrough or provide patient care, there's a role for you that fuels your passion and takes advantage of your skills. There are career opportunities available in academics, research, hospital medicine, physician practices and support services, from patient billing to IT.

The Clinical and Translational Science Award (CTSA) Program aims to advance clinical and translational science to increase the speed at which new treatments become available to patients. MUSC Health, the clinical enterprise, operates a 750 bed medical center, which includes a nationally recognized Children's Hospital, the Ashley River Tower (cardiovascular, digestive disease, and surgical oncology), Hollings Cancer Center (one of fewer than 70 elite National Cancer Institute designated centers), a Level I Trauma Center and the Institute of Psychiatry. In addition, there are more than 100 outreach clinics, hospital/health system affiliations, and telehealth sites. U.S. News & World Report placed us among the top one percent of all American hospitals, with 11 specialties in the top 50. The MUSC Medical Center is also one of only three Magnet designated hospitals in South Carolina.