Patient Care

• Conduct Chronic Care Management (CCM) follow-up calls with eligible patients
• Build positive relationships with patients and encourage ongoing engagement in their care plans
• Accurately document all patient interactions and care activities within established timelines
• Maintain and update CCM tracking logs using Google Drive and Google Sheets
• Utilize Office Ally as the primary Electronic Health Record (EHR) system
• Coordinate patient care activities and ensure all required documentation is complete and compliant
• Monitor patient progress and escalate concerns to the appropriate clinical team when necessary
• Collaborate with providers and other healthcare professionals to support continuity of care
• Maintain strict HIPAA compliance and protect patient confidentiality at all times
• Perform additional administrative and care coordination duties as assigned

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Chronic Care Management Specialist – Patient Ally, English & Spanish