Chronic Care Management (CCM) Care Coordinator

Your Role

The Evergreen Chronic Care Management (CCM) Care Coordinator supports proactive care coordination services for patients with complex chronic conditions, including chronic kidney disease (CKD), hypertension, diabetes, cardiovascular disease, and related comorbidities. Working under Evergreen’s clinical supervision, the Care Coordinator conducts patient outreach, creates, maintains, and reinforces established care plans, supports documentation compliance, and coordinates communication between patients, providers, and healthcare partners.

This role is outreach-driven and operationally focused, requiring strong organization, patient communication skills, and the ability to manage a high-volume patient panel. Experience supporting nephrology or CKD patient populations is strongly preferred.

The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.

While this position is fully remote, you must be able to work 8:00am – 5:00pm in the central time zone.

Role Responsibilities

Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:

• Patient Enrollment & Eligibility
  • Support CCM patient enrollment and onboarding activities.
  • Verify eligibility based on Evergreen and payer program guidelines.
  • Ensure patient consent documentation is completed prior to outreach.
  • Proactively maintain patient engagement regularly.
  • Identify inactive or non-engaged patients and escalate appropriately.
• Patient Outreach & Engagement
  • Conduct text & telephonic outreach to enrolled CCM patients weekly.
  • Achieve required engagement time standards aligned with Medicare CCM billing requirements.
  • Support achievement of required engagement time for billing compliance.
  • Reinforce provider-directed care plans during patient interactions.
  • Identify barriers to adherence including medication access, transportation, or social needs.
• Expected activities include:
  • High-volume outbound patient calling and texting.
  • Follow-up outreach attempts.
• Documentation & Billing Compliance
  • Document patient interactions accurately within the CCM patient management platform and EHR systems.
  • Track engagement time consistent with Medicare CCM billing requirements.
  • Maintain audit-ready documentation standards.
  • Ensure HIPAA and PHI compliance.
• Patient Care Coordination & Clinical Workflow
  • Facilitate patient access to their referring provider and clinical staff.
  • Support care transitions following hospitalizations or ED visits.
  • Coordinate referrals and follow-up appointments.
  • Escalate symptom concerns or medication issues to licensed clinical staff.
• Preferred experience includes:
  • Chronic kidney disease patient populations.
  • Dialysis patient coordination.
  • Medication adherence monitoring.
  • Kidney transplant or specialty referrals.
• Technology & Communication
  • Utilize CCM platform and EHR systems daily.
  • Manage patient messaging workflows.
  • Collaborate with remote clinical and operational teams.

Required Qualifications

• Certified Medical Assistant
• Bilingual (Spanish/English)
• 1–3 years healthcare experience
• Chronic disease or nephrology experience is preferred.
• Strong clinical assessment, communication, and documentation skills.
• Comfortable working in two systems (EHR + CCM platform) simultaneously.
• Ability to manage a structured, metric-driven workflow with reliability.
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily remote environment:
  • Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
  • Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
  • Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Experience in chronic disease management
• Prior work in virtual care, remote nursing, or telehealth programs.
• Familiarity with CCM regulatory requirements.
• Strong patient education and motivational interviewing skills.