Job Description
Job Description
Overview
The CCM & TCM Care Coordinator is responsible for providing non–face-to-face care coordination services to patients enrolled in Chronic Care Management (CCM) and Transitional Care Management (TCM) programs. This role supports patients with multiple chronic conditions and those transitioning from inpatient or emergency care, ensuring continuity of care, medication reconciliation, care plan updates, and compliance with CMS documentation and billing requirements.
This position works under general supervision of the billing provider and plays a critical role in quality outcomes, patient satisfaction, and program compliance.
Key Responsibilities:
Chronic Care Management (CCM):
- Identify and support patients eligible for CCM services
- Conduct monthly non–face-to-face care coordination activities (minimum 20 minutes per month)
- Maintain and update comprehensive electronic care plans
- Perform medication reviews and reconciliation
- Communicate with patients, caregivers, specialists, pharmacies, and community resources
- Track and document CCM time accurately in the EMR
- Ensure CCM consent is obtained and documented
- Prepare monthly CCM documentation for provider review and attestation
Transitional Care Management (TCM):
- Conduct post-discharge outreach within CMS-required timeframes
- Perform medication reconciliation following hospital or ER discharge
- Identify and address gaps in care after transitions
- Coordinate follow-up appointments and referrals
- Document all TCM-related activities in compliance with CMS guidelines
Documentation & Compliance:
- Document all care coordination activities clearly and timely
- Ensure documentation meets CMS, payer, and internal audit standards
- Assist with chart audits and compliance reviews
- Flag incomplete documentation or missing requirements prior to billing
- Maintain confidentiality and HIPAA compliance at all times
Qualifications & Skills:
- Medical Assistant (MA), Care Coordinator, or equivalent clinical experience
- Preferred 1–2 years of experience in care coordination, chronic care management, case management, or clinical support
- Strong understanding of chronic disease management
- Experience with EMR/EHR systems
- Excellent verbal and written communication skills
- Strong organizational and time-management abilities
- Experience working with Medicare patients
- Familiarity with CCM (CPT 99490, 99439) and TCM (99495, 99496) programs
Benefits:
- Flexible spending account
- Paid time off
- 401K
- Competitive salary based on experience.
- Comprehensive benefits package, including health, dental, and vision insurance.
- Paid time off and professional development opportunities.
Join us in making a difference in our patients' lives by providing exceptional care coordination!
Job Types: Full-time
Pay: $18.00 - $24.00 per hour
Expected hours: No less than 40 per week
Schedule:
Monday to Friday
Work Location: In person
This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
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