Job Overview We are seeking a dedicated and compassionate Chronic Care Management (CCM) Specialist to join our healthcare team. In this vital role, you will coordinate and deliver comprehensive care plans for patients with complex, chronic health conditions. Your expertise will help improve patient outcomes, enhance quality of life, and reduce unnecessary hospital visits. The ideal candidate will possess a strong background in nursing, hospital experience, and managed care, with a passion for patient-centered service. This paid position offers an exciting opportunity to make a meaningful difference in the lives of diverse patient populations through proactive engagement and coordinated care strategies. Duties Develop and implement individualized care plans for patients with chronic illnesses, ensuring alignment with medical guidelines and patient needs Conduct regular patient outreach via phone, telehealth, or in-person visits to monitor health status and adherence to treatment plans Collaborate with multidisciplinary teams including social workers, behavioral health specialists, and healthcare providers to coordinate services such as discharge planning, social services, and hospice care Utilize EMR (Electronic Medical Records) and EHR (Electronic Health Records) systems to document patient interactions, update care plans, and track progress Educate patients on managing their conditions effectively, including medication adherence, lifestyle modifications, and symptom management Assist in utilization management by reviewing patient cases for appropriate resource use within managed care frameworks Support intake processes for new patients and facilitate communication across diverse cultural backgrounds to ensure equitable access to care Experience Background in primary care, nursing or social work with familiarity in behavioral health and hospice environments Proficiency in EMR/EHR systems, Microsoft Office suite, and medical terminology is essential Knowledge of HIPAA regulations, health insurance processes, CPT coding, ICD-10/ICD-9 coding standards, and discharge planning procedures is required Experience working with individuals from diverse cultural backgrounds to deliver culturally competent care Prior case management or utilization management experience within managed care organizations is advantageous Bilingual skills are a plus to effectively serve a broader patient demographic Join us in transforming healthcare delivery by providing proactive chronic care management that empowers patients and elevates their quality of life. We're committed to fostering an inclusive environment where your expertise makes a real impact!