Chronic Care Management Coordinator LMCH


Chronic Care Coordinator Job Description

Lake Martin Community Hospital is looking to hire a full-time Chronic Care Management Coordinator. Pay to be determined; DOE. Full-Time benefits include:

  • Health
  • Dental
  • Vision
  • 401 K
  • Flex Spending Account
  • PTO
  • Short term/Long term Disability

SUMMARY OF DUTIES:   The Chronic Care Coordinator performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Chronic Care Coordinator works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision-making.


  • Can fulfill the clinic’s mission through quality healthcare to those in need while providing appropriate care for the whole person.
  • Responsible for registry of chronic care management (CCM) patients.
  • Validates enrollment of CCM patients based on provider request
  • Conducts minimum of one 20 minute of telephone or in-person counseling and education per month to each CCM patient on roster.
  • Complies with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the HER.
  • Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.
  • Creates an ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire.
  • Facilitates patient access to appropriate medical and specialty providers.
  • Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates.
  • Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education.
  • Educates patient and family/caregiver(s) about relevant community resources
  • Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.
  • Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
  • Supports patient self-management of disease and behavior modification interventions.
  • Provides patient health counseling, education and instruction.


  • Graduate of accredited CMA/RMA program, preferred
  • Current CMA/RMA certification, preferred


  • Minimum of 1-3 year work experience in a healthcare setting involving patients with complex chronic disease states preferred