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Valora Medical Group is a visionary company focused on high-quality primary care and value-based care services, consisting of healthcare providers and professionals dedicated to the health and wellbeing of our patients. At Valora, we treat our patients as family.

We are looking for a Chronic Care Management (CCM) Coordinator to support patients with chronic conditions by coordinating their ongoing care and helping them achieve better health outcomes. In this role, you will work closely with providers, clinical staff, patients, caregivers, and community resources to ensure continuity of care, promote patient engagement, and assist with care plan implementation.

The Chronic Care Management (CCM) Coordinator is responsible for coordinating patient care across the continuum with a focus on improving clinical outcomes, reducing avoidable hospital utilization, and enhancing the patient experience. This position supports value-based care initiatives through Transitional Care Management, Chronic Care Management, and Utilization Management.

The coordinator serves as a liaison between patients, providers, hospitals, specialists, health plans, caregivers, and community resources to ensure patients receive timely, coordinated, and comprehensive care.

ESSENTIAL RESPONSIBILITIES

• Monitor daily hospital admission, discharge, and emergency department reports to identify patients requiring follow-up.
• Coordinate Transitional Care Management (TCM) services, including timely patient outreach, scheduling post-discharge appointments, medication reconciliation, and patient education.
• Enroll and manage eligible patients in Chronic Care Management (CCM) programs in accordance with CMS guidelines.
• Develop, implement, and maintain individualized care plans in collaboration with providers and the interdisciplinary care team.
• Educate patients and caregivers on chronic disease management using language appropriate to the patient's level of health literacy.
• Encourage medication adherence, preventive care, and routine follow-up appointments through evidence-based patient education and motivational interviewing techniques.
• Assess barriers to care, including financial, transportation, social, cultural, and health literacy concerns, and coordinate appropriate resources.
• Build trusting relationships with patients to improve participation in their care plans and support long-term disease management.
• Conduct patient outreach to assess health status, medication adherence, barriers to care, and social determinants of health.
• Collaborate with providers, medical assistants, office staff, hospitals, specialists, and health plans to ensure continuity of care.
• Support patients and caregivers by providing education regarding disease management, medications, treatment plans, and available healthcare resources.
• Monitor high-risk patient populations and assist with interventions designed to reduce emergency department utilization, hospital admissions, and readmissions.
• Assist the Utilization Management team by monitoring inpatient census reports, reviewing utilization trends, and identifying patients requiring additional care coordination.
• Maintain accurate, timely, and compliant documentation within the electronic medical record (EMR).
• Assist with quality improvement initiatives, regulatory compliance, and population health programs.
• Participate in multidisciplinary meetings, case reviews, and performance improvement initiatives.
• Perform additional duties as assigned to support departmental and organizational goals.

QUALIFICATIONS

Education amp; Experience

• Preferred: Foreign Medical Graduate (FMG/IMG).
• Licensed Practical Nurse (LPN)
• Medical Assistant with a minimum of 5 years of clinical experience, preferably in a primary care or value-based care setting.
• Minimum of 2 years of experience in care coordination, chronic care management, transitional care management, utilization management, case management, population health, or a related healthcare role.
• Experience working with Medicare Advantage, CMS care management programs, and value-based care initiatives strongly preferred.
• Proficiency with electronic medical records (EMR), and Microsoft Office Suite.

Required:

• Bilingual fluency in English and Spanish, both verbal and written

KNOWLEDGE, SKILLS amp; ABILITIES

• Strong understanding of chronic disease management, care coordination, and population health principles.
• Knowledge of CMS guidelines related to Transitional Care Management (TCM) and Chronic Care Management (CCM).
• Knowledge of common chronic diseases, including Diabetes, Congestive Heart Failure (CHF), COPD, Hypertension, Hyperlipidemia, Coronary Artery Disease, and Chronic Kidney Disease.
• Familiarity with utilization management processes and hospital discharge planning.
• Ability to recognize clinical red flags and appropriately escalate patient concerns while remaining within scope of practice.
• Strong critical thinking and sound clinical judgment.
• Excellent communication, interpersonal, and patient engagement skills.
• Strong motivational interviewing and patient coaching skills.
• Ability to explain complex medical conditions in simple, patient-friendly language.
• Ability to manage sensitive conversations with empathy, professionalism, and cultural awareness.
• Strong organizational, analytical, and problem-solving abilities.
• Ability to manage multiple priorities while maintaining attention to detail.
• Ability to work collaboratively within a multidisciplinary healthcare team.
• Demonstrates professionalism, compassion, and a patient-centered approach to care.
• Commitment to patient-centered care and improving health outcomes through education, engagement, and proactive care coordination.

PERFORMANCE EXPECTATIONS

Success in this role will be measured by:

• Timely completion of Transitional Care Management outreach.
• Chronic Care Management enrollment and monthly patient engagement.
• Post-discharge follow-up appointment completion.
• Reduction in avoidable emergency department visits and hospital readmissions.
• Accurate and compliant clinical documentation.
• Patient satisfaction and engagement.
• Achievement of organizational quality and population health goals.

EEO Statement: Valora Medical Group, LLC is an equal opportunity employer and does not discriminate on the basis of race, color, religion, creed, sex, national origin, age, disability, pregnancy status, sexual orientation, gender identity, veteran status, marital status, genetic information, citizenship status, or other status protected by law. In compliance with the Immigration Reform and Control Act of 1986, we will hire only U.S. citizens and aliens lawfully authorized to work in the United States.