Chronic Care Management Team Lead

4 days ago

Phoenix, United States Desert Valley Hospice and Palliative Care Full-time $24 - $34 Contract

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Chronic Care Management Team Lead – LPN or Experienced Medical Assistant (MA)

Alliance Medical Clinic | Desert Valley Palliative Care

Location: Phoenix, Arizona – Hybrid (Primarily Remote)

Job Type: Full-Time

Compensation:

Medical Assistant (MA): $24–$26 per hour, based on experience.
Licensed Practical Nurse (LPN): $34 per hour.

Position Overview:

We are seeking an experienced, medically knowledgeable, and highly motivated Chronic Care Management Team Lead to join our growing primary care, mobile medical, and palliative care programs.

This individual will work closely with our existing care management coordinator, physicians, nurse practitioners, and interdisciplinary clinical team to help oversee daily care management activities, improve patient outcomes, and ensure continuity of care for patients with chronic and complex medical conditions.

The ideal candidate has strong clinical knowledge, excellent organizational skills, leadership abilities, and experience in chronic disease management, patient education, or care coordination.

This is a hybrid position, primarily working from home, with occasional visits to our medical offices, assisted living facilities, skilled nursing facilities, and other patient care locations.

Key Responsibilities:

Team Leadership & Program Support:

Help lead daily Chronic Care Management (CCM) activities and support the care management team.
Collaborate with the existing care management coordinator to ensure efficient workflows, patient follow-up, and timely documentation.
Monitor patient outreach, care plan completion, and overall program performance.
Assist with staff education, workflow improvements, and quality assurance.
Identify opportunities to improve patient engagement, operational efficiency, and care management outcomes.
Serve as a clinical resource within the limits of professional training and licensure.

Chronic Disease Management:

Support ongoing management of patients with diabetes, hypertension, congestive heart failure, COPD, coronary artery disease, dementia, and other chronic illnesses.
Review patient medical histories, medications, and treatment plans.
Monitor patient needs through regular telephone outreach and follow-up.
Identify changes in patient status and escalate concerns to appropriate providers.
Assist with care plan development, implementation, and follow-up.
Coordinate appointments, referrals, diagnostic testing, and specialty care.
Support medication reconciliation, adherence, and patient education within scope of practice.

Quality Measures & Population Health:

Identify and help close gaps in care, including preventive screenings, laboratory monitoring, vaccinations, and chronic disease follow-up.
Support HEDIS, Medicare Advantage, and value-based quality initiatives.
Coordinate Medicare Annual Wellness Visits and preventive health services.
Assist with chronic condition documentation and risk adjustment initiatives.
Track quality outcomes and identify opportunities for improvement.

Transitional Care Management:

Coordinate care for patients discharged from hospitals, rehabilitation centers, and skilled nursing facilities.
Ensure timely post-discharge outreach and follow-up appointments.
Review discharge instructions, medication changes, and ongoing care needs.
Communicate with patients, caregivers, providers, and facilities.
Help reduce unnecessary emergency department visits and hospital readmissions.

Mobile Medicine & Palliative Care:

Support care management for homebound, medically complex, and palliative care patients.
Collaborate with mobile physicians, nurse practitioners, facility staff, and home health agencies.
Identify patients who may benefit from additional medical, palliative, or supportive services.
Participate in occasional facility visits for patient follow-up, education, and care coordination.
Assist with communication among patients, families, caregivers, and providers.

Patient Education & Care Coordination:

Educate patients regarding chronic illnesses, medication adherence, preventive care, and treatment plans.
Identify barriers to healthcare, i

Chronic Care Management Team Lead

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