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Home Based Chronic Care Management Jobs (NOW HIRING)

Medlink Georgia

Chronic Care Manager

Commerce, GA · On-site

Responsible for facilitating care coordination services for Medicare Chronic Care Management ... Coordination with home and community-based clinical service providers as appropriate, with ...

University of North Dakota

Chronic Care Nurse

Bismarck, ND · On-site

$32 - $35/hr

Their responsibilities encompass a wide range of activities, including patient education on medication management, lifestyle modifications, and self-care techniques. Chronic Care Nurses often act as ...

Vitability Health

Chronic Care Manager

Brooklyn, NY · On-site

$23 - $33/hr

Provides follow-up management with patients to ensure compliance with their individual care plan ... May conduct home visits with a physician in order to assess safety, medication compliance, and home ...

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Home Based Chronic Care Management information

What is home based chronic care management?

Home Based Chronic Care Management (CCM) is a healthcare service designed to help patients with multiple or severe chronic conditions manage their health from the comfort of their own homes. This service typically involves regular check-ins, care coordination, medication management, and health monitoring, often led by nurses or other healthcare professionals. The goal is to improve patient outcomes, prevent complications, and reduce hospitalizations by providing ongoing support and personalized care plans. CCM is especially beneficial for patients who have difficulty traveling to clinics or require continuous oversight due to their medical conditions.

What are the key skills and qualifications needed to thrive in home based chronic care management?

To thrive in Home Based Chronic Care Management, you need a background in nursing, social work, or allied health, with expertise in chronic disease management and care coordination. Familiarity with telehealth platforms, electronic health records (EHRs), and case management software is typically required. Exceptional communication, problem-solving, and empathy are vital soft skills for engaging patients and collaborating with multidisciplinary teams remotely. These skills ensure effective patient support, adherence to care plans, and improved health outcomes for individuals managing chronic conditions at home.

What are the main challenges faced by professionals in home based chronic care management, and how can they be addressed?

One of the main challenges in Home Based Chronic Care Management is effectively coordinating care among multiple healthcare providers while communicating consistently with patients and their families. Professionals often work remotely and must rely on digital tools to monitor patient progress, which can make it harder to build rapport and quickly address urgent concerns. To overcome these challenges, successful care managers prioritize strong organizational skills, regular virtual check-ins, and proactive communication strategies, ensuring all stakeholders remain informed and engaged in the patient's care plan.

What is the difference between Home Based Chronic Care Management vs Home Health Aide?

AspectHome Based Chronic Care ManagementHome Health Aide
CertificationsCCM certification, healthcare trainingCertified Nursing Assistant (CNA) or equivalent
Work EnvironmentRemote, patient homes, healthcare settingsPatient homes, healthcare facilities
Job FocusManaging chronic conditions, care coordinationAssisting with daily living activities
Employer & IndustryHealthcare providers, insurance companiesHome health agencies, hospitals

Home Based Chronic Care Management involves coordinating care for patients with chronic conditions, often remotely, requiring healthcare certifications. In contrast, Home Health Aides assist with daily activities in patients' homes, typically with CNA credentials. Both roles serve in home settings but focus on different aspects of patient care.

More about Home Based Chronic Care Management jobs

What cities are hiring for Home Based Chronic Care Management jobs?

Cities with the most Home Based Chronic Care Management job openings:

What are the most commonly searched types of Chronic Care Management jobs?

The most popular types of Chronic Care Management jobs are:

What states have the most Home Based Chronic Care Management jobs?

States with the most job openings for Home Based Chronic Care Management jobs include:

What job categories do people searching Home Based Chronic Care Management jobs look for?

The top searched job categories for Home Based Chronic Care Management jobs are:

Home Based Chronic Care Management jobs near you
Infographic showing various Home Based Chronic Care Management job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 78% Full Time, 14% Part Time, and 7% Contract. Highlights an 86% Physical, 2% Hybrid, and 12% Remote job distribution.

Chronic Care Management Specialist

Bullhook Community Health Center

Havre, MT • On-site

$43K - $76K/yr

Full-time

Re-posted 27 days ago

Job description

Bullhook Community Health Center (BCHC) is an equal opportunity employer.  BCHC shall, upon request, provide reasonable accommodation to otherwise qualified individuals with disabilities.

Job Title: Chronic Care Management
Supervisor: CMO
Department: Medical
Supervises: N/A
Salary: 
  • $43,212.00 - $61,609.98 ($20.78-$29.62/hr) Medical Assistant
  • $57,204.79 - $76,878.45 ($27.50-36.96/hr) Registered Nurse

Job Overview:
Individuals will be responsible for assisting medical providers in the management of high-risk, chronic illness patients to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve the quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of healthcare delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the community.
Essential Functions (Major Duties or Responsibilities):
  • Collaborates with providers and clinic staff in identifying appropriate patients for care management, utilizing established care management criteria.
  • Performs initial and periodic holistic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient. Performs Medicare Annual Wellness Visits for clients as appropriate.
  • Prioritize patients according to medical complexity, need and required follow up.
  • Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; and educating the patient/family on the choices available.
  • Establishes a person-centered electronic care plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients that are action oriented.
  • Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals.
  • Monitors and evaluates the progress of the patient.
  • Collaborate with the healthcare team to revise the care management plan when changes occur.
  • Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
  • Identifies and effectively utilizes community resources to meet the needs of patients/families. Facilitates patient access to community resources as appropriate.
  • Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
  • Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
  • Performs follow-up calls for patients recently discharged from acute hospitalizations.
  • Maintains EMR database on care managed population. Maintains accurate and timely documentation in the EMR.
  • Reviews utilization and quality reports monthly and scans for gaps in care to identify patients needing the additional support of care management.
  • Ensures all rules and requirements set forth by the Centers for Medicare and Medicaid for Chronic Care Management are being met.
  • Performs medication reconciliation for all care transitions.
  • Participate in community preventative health activities i.e. school-based flu clinics.
  • Participates in the orientation of new personnel.
  • Will meet monthly, quarterly, and yearly metrics as indicated.
  • Precepts and mentor’s peers.
  • Promotes collaborative teamwork.
  • Abides by the organization’s compliance program and requirements.
  • Provides coverage across the organization as needed.
  • Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
  • Performs other duties as assigned.

Minimum Qualifications (Education and Experience):
  • Minimum of 3 years of professional-level medical experience; experience in care coordination is strongly preferred.
  • RN or LPN licensure preferred.
  • A certified Medical Assistant with extensive care coordination experience will be considered.
  • Experience working with an electronic medical record is required.
  • Ability to work collaboratively with people of diverse cultures and lifestyles.
  • Ability to communicate effectively with providers and medical staff.
  • Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
  • Ability to be self-motivating and work independently.
  • Computer skills proficient to expert.
  • Excellent written and oral communication skills.
  • Problem-solving skills.
  • Proficiency in medication indications and side effects.
  • Understanding of medical tests and requirements to provide the patients with appropriate information.

Knowledge, Skills, and Abilities (KSA’s):
  • Knowledge of principles, practices, and procedures of clinical nursing. Related community health center laws and regulations.
  • Thorough knowledge of phlebotomy, immunizations, communicable diseases, CPR, and other related nursing procedures.
  • Thorough knowledge of mental health and substance use disorders, treatments, and crisis intervention management.
  • Ability to perform nursing duties in a professional manner.
  • Communicate with clients, families, employees, and healthcare professionals.
  • Good organizational skills to handle multiple priorities while remaining professional and calm.
  • Ability to work with many diverse people.
  • Effective telephone skills.
  • Strong level of confidentiality due to the sensitivity of materials and information handled.
  • Must be able to make suggestions on workflow or system efficiency and effectiveness.
  • Ability to work independently and be self-directed and flexible.
  • Ability to prioritize. Ability to perform functions with minimal supervision.
  • Ability to work at a high-volume level of accuracy.

Supervision: N/A
Physical and Environmental Demands:
Work is performed in an office and clinic setting; stands, walks with intermittent sitting; reaches for and uses writing instruments and keyboard; reads reports and other written materials; extensive use of telephone and oral communication with the public and coworkers; stoops; bends; kneels; reaches for; picks up; and pushes or pulls; ability to lift up to 30 pounds.
Special Requirements:
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria considered necessary to perform the job successfully.