Medical Assistant CCM Chronic Care Coordinator

Desert Ridge Family Physicians; Phoenix (AZ); On-site; USD 46,000 - 62,000; Full time

Benefits offered by this job

401(k) matching

Competitive salary

Dental insurance

Health insurance

Vision insurance

Job summary

Desert Ridge Family Physicians is seeking a care coordination-focused professional to support Chronic Care Management (CCM) and Transitional Case Management (TCM). You will conduct outreach, education, and coordination to improve chronic disease outcomes, while ensuring accurate documentation in the EHR.

The role emphasizes teamwork, adherence to structured workflows, and proactive communication with leadership to address patient needs and workflow challenges.

Qualifications

• Experience in care coordination, chronic care management, or a similar patient-facing healthcare role.
• Patient-centered and team-oriented.
• Medical Assistant experience preferred.
• Organized, dependable, and able to work independently within defined workflows.
• Ability to follow structured workflows with strong attention to detail.

Responsibilities

• Manage a panel of CCM and TCM patients with timely outreach and documentation.
• Conduct patient outreach, follow-ups, and education to support chronic disease management.
• Assist with medication reconciliation, referrals, and care coordination.
• Help patients navigate appointments, labs, imaging, and community resources.
• Document all care management activities accurately in the EHR.
• Provide care management including phone-based outreach and in-office support as needed.
• Work closely with physicians and clinical staff to support care plans.
• Follow CCM and TCM workflows to ensure consistency and compliance.

Skills

Chronic care management

Care coordination

Team collaboration

Medical Assistant experience

Attention to detail

Time management

Clear communication with leadership

Education

Experience as Medical Assistant

Tools

Athena EHR

Job description

Benefits:

• 401(k) matching
• Competitive salary
• Dental insurance
• Health insurance
• Vision insurance

Chronic Care Management

• 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.

Care Coordination & Team Collaboration

• Work closely with physicians, supervisors, and clinical staff to support patient care plans.
• Follow established CCM and TCM workflows to ensure consistency and compliance.
• Escalate concerns, barriers, or process improvement ideas through leadership channels.
• Participate in team meetings and ongoing training.

What we are looking for

• Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role.
• Patient centered and Team oriented
• Medical Assistant experience preferred .
• Organized, dependable, and able to work independently within defined workflows.
• Able to follow structured workflows while maintaining strong attention to detail and accountability for assigned tasks.
• Understands role responsibilities and maintains appropriate professional boundaries within a team-based care model.
• Able to manage a high-volume workload, prioritize tasks effectively, and meet deadlines in a fast-paced environment.
• Communicates clearly and proactively with leadership regarding patient needs, barriers, and workflow concerns.
• Open to feedback, coaching, and professional development.
• Experience with Athena EHR or similar systems preferred.

Why You'll Love Working Here

• Supportive leadership with clear expectations, structured workflows, and accountability.
• Established systems that allow you to focus on patient care without unnecessary chaos.
• Opportunities to build skills in CCM, TCM, and care coordination.
• A collaborative environment that values teamwork, consistency, and growth.
• Meaningful work that helps reduce hospitalizations and improve patient outcomes.

This role requires strong time management, attention to detail, and the ability to work within established processes.

We offer full medical benefits Paid 100% for employee
401k w/ 4% Match at 6 months
competitive salary & PTO