Chronic Care Specialist CCM

Job Summary:
We are seeking an experienced Medical Assistant to join our Chronic Care Management team in a stationary, phone-based role. This position involves working closely with providers and patients to develop and implement comprehensive, goal-driven care plans. The Medical Assistant will use clinical expertise to address chronic conditions and identify barriers related to behavioral health, social determinants, and care access.

Key Responsibilities:

Conduct patient outreach via telephone to assess needs and provide ongoing support

Develop and manage individualized care plans in collaboration with providers

Coordinate care across healthcare and community resources (e.g., hospitals, home health, senior services)

Advocate for patients and facilitate smooth care transitions between settings

Address clinical, psychosocial, and medication-related concerns

Qualifications:

1–2 years of experience as a Medical Assistant (preferred in primary care, public health, or care coordination)

Strong knowledge of patient charting and chronic disease management (preferred)

Excellent communication and interpersonal skills

Ability to multitask and work independently with minimal supervision

We are an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We are a drug-free work place and all offers of employment are contingent upon passing a pre-employment drug screen.