The Chronic Care Coordinator supports patients enrolled in CMS Chronic Care Management (CCM) programs by delivering non–face-to-face care coordination services in accordance with Medicare guidelines. This remote role focuses on managing patients with two or more chronic conditions through ongoing monitoring, care plan management, patient education, and care team collaboration to improve outcomes and reduce avoidable utilization.

Key Responsibilities

· Provide CMS-compliant Chronic Care Management (CCM) services for eligible Medicare patients with two or more chronic conditions expected to last at least 12 months.

· Conduct non–face-to-face patient outreach via phone, secure messaging, and telehealth platforms to meet monthly CCM time requirements.

· Develop, document, and maintain comprehensive electronic care plans addressing medical, functional, psychosocial, and preventive care needs.

· Perform monthly care coordination activities, including medication reconciliation support, appointment coordination, and follow-up on care gaps.

· Educate patients and caregivers on chronic disease management, medication adherence, lifestyle modifications, and self-management strategies.

· Identify and address barriers to care, including social determinants of health, and connect patients with community and clinical resources.

· Coordinate communication between patients, primary care providers, specialists, pharmacies, and other care team members.

· Accurately track, document, and report billable CCM time in compliance with CMS guidelines and organizational policies.

· Ensure patient consent for CCM services is obtained, documented, and maintained per CMS requirements.

· Support quality measures, risk stratification efforts, and care gap closure initiatives.

· Maintain strict compliance with HIPAA, CMS regulations, and internal compliance standards.