Licensed Practical Nurse - Chronic Care Management

United StatesRemotemid

OtherLicensed Practical Nurse

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Quick Summary

Requirements Summary

Health, dental, vision, and life insurance Employer Sponsored Retirement Plan Paid time off and extended sick leave Pa

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OtherLicensed Practical Nurse

The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) outreach to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient outcomes, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through structured monthly outreach, education, care plan management and promotes patient well-being through timely follow-up, education, and coordination of services.

MUSC Community Physicians (MCP)

Employee

Regular

CC005802 MCP - Population Health Transitional Care Management (TCM)

Hourly

Health-25

Responsibilities

~1 min read

• 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

Requirements

~1 min read

• 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