Licensed Practical Nurse-4

• Conduct monthly telephonic outreach to assigned CCM patient panel
• Complete a minimum of 20 minutes of non–face-to-face care management services per patient per calendar month
• Perform at least two outreach attempts for patients not reached
• Assess patient status, including changes in condition, symptoms, or care needs
• Review and reinforce individualized care plans and patient goals
• Support medication adherence and identify potential medication concerns
• Identify and address barriers to care (e.g., transportation, access to medications, social needs)
• Assist with scheduling appointments when clinical evaluation is needed
• Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards
• Document all interactions accurately in the electronic health record (EHR) and track time for billing compliance
• Collaborate with providers, care teams, and community resources to ensure continuity of care

• Provide education on chronic disease management and preventive care
• Encourage patient participation in primary care and adherence to treatment plans
• Monitor for signs of deterioration and escalate concerns appropriately
• Support transitions of care when applicable
• Promote patient self-management and engagement in their health

• Strong communication and interpersonal skills
• Ability to assess patient needs and apply clinical judgment appropriately
• Proficiency in EHR documentation and care coordination workflows (experience with Epic Systems preferred)
• Knowledge of chronic disease management and population health principles
• Ability to manage a high-volume patient panel efficiently
• Strong organizational and time management skills
• Ability to work independently within established workflows and SOPs
• Ability to appropriately route communication to providers vs. clinical support teams

• Active LPN licensure in good standing (South Carolina preferred)
• BLS (Basic Life Support) certification (if required by role)
• Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred
• Experience working with high-risk or chronic condition populations strongly preferred