LPN: Chronic Care Outreach & Care Coordination

Medical University of South Carolina; South Carolina; On-site; USD 30,307 - 46,838; Full time

Benefits offered by this job

Health insurance

Dental & vision coverage

Paid time off

Tuition reimbursement

Flexible schedule options

Job summary

The Medical University of South Carolina’s MUSC Community Physicians (MCP) is seeking an LPN Care Team Member to perform Chronic Care Management outreach and coordinate care for patients with two or more chronic conditions. The role emphasizes structured monthly outreach, education, care plan management, and timely follow-ups to improve outcomes and reduce hospital utilization.

Responsibilities include telephonic outreach, care plan reinforcement, medication adherence support, and collaboration

Qualifications

• Active LPN licensure in good standing (SC preferred).
• BLS certification (if required by role).
• Experience in care coordination, case management, ambulatory care, or chronic disease management preferred.
• Experience with high-risk or chronic condition populations strongly preferred.
• Proficiency in Epic EHR documentation and care coordination workflows.

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 month.
• Perform at least two outreach attempts for patients not reached.
• Assess patient status and 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 barriers to care and assist with scheduling appointments as needed.
• Escalate clinical concerns per workflow standards.

Skills

Communication

Care coordination

EHR proficiency

Clinical judgment

Time management

Independent work

Tools

Epic Systems

Job description

The Medical University of South Carolina’s MUSC Community Physicians (MCP) is seeking an LPN Care Team Member to perform Chronic Care Management outreach and coordinate care for patients with two or more chronic conditions. The role emphasizes structured monthly outreach, education, care plan management, and timely follow-ups to improve outcomes and reduce hospital utilization.

Responsibilities include telephonic outreach, care plan reinforcement, medication adherence support, and collaboration