Job Description

Position Summary:

The Telehealth Chronic Care Management (CCM) Specialist is responsible for supporting patients with chronic conditions through ongoing remote monitoring, care coordination, and engagement. This role works closely with providers, care teams, and patients to ensure adherence to care plans, improve health outcomes, and reduce hospitalizations using telehealth platforms.

Key Responsibilities

• Conduct routine telephonic or virtual check-ins with patients enrolled in Chronic Care Management programs
• Monitor patient health status, symptoms, and adherence to treatment plans
• Document all patient interactions and time spent in accordance with CMS Chronic Care Management Program guidelines
• Assist in developing and updating individualized care plans under provider supervision
• Coordinate care between primary care providers, specialists, pharmacies, and other healthcare services
• Identify changes in patient condition and escalate concerns to clinical staff appropriately
• Educate patients on disease management, medications, lifestyle modifications, and preventive care
• Ensure compliance with HIPAA and patient confidentiality standards
• Track and report CCM metrics including patient engagement, time logs, and quality outcomes
• Support billing documentation and audit readiness for CCM services

Qualifications

• High school diploma required; Associate’s or Bachelor’s degree in healthcare-related field preferred
• Certification or experience in medical assisting, care coordination, or population health strongly preferred
• Familiarity with chronic conditions such as diabetes, hypertension, COPD, and heart disease
• Experience with EMR/EHR systems and telehealth platforms
• Strong communication and patient engagement skills
• Ability to manage a high volume of patient interactions and documentation

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