Chronic Care Management Coordinator, MA
2 days ago
Dallas
Job Description Southwest Medical Group Are you a compassionate, motivated CCM Coordinator looking to join an exciting care team. This full-time role offers a meaningful opportunity to make a direct impact on the lives of Medicare and high-risk patients while building advanced clinical, care coordination, and population health skills in a supportive, team-oriented environment. This position is ideal for a Medical Assistant with Chronic Care Management experience or an International Medical Graduate (IMG) who is not currently pursuing residency—or who is seeking a rewarding clinical role with a minimum two-year commitment prior to applying. You will work closely with providers and care teams to deliver Chronic Care Management (CCM) and/or Advanced Primary Care Management services, helping patients navigate their care, overcome health barriers, and achieve better long-term outcomes. In this role, you will gain hands-on experience supporting complex patient needs, closing care gaps, and contributing to the daily operations of a thriving primary care practice. This is an excellent opportunity for someone who is eager to grow professionally, expand clinical knowledge, and be part of an organization that values learning, collaboration, and compassionate care. Key Responsibilities • Conduct monthly check-in calls with patients enrolled in CCM/APCM programs, fostering consistent engagement and continuity of care, • Build strong, trusting relationships that empower patients to take an active role in managing their health, • Collaborate closely with primary care providers to develop, implement, and update individualized care plans, • Review medical records to identify care gaps, health goals, and potential barriers to treatment adherence, • Apply motivational interviewing techniques to support sustainable behavior change and improve outcomes, • Monitor patient status and promptly communicate changes or concerns to the care team, • Coordinate care with external partners, including DME vendors, home health agencies, and family caregivers, • Provide education on chronic disease management, preventive care, health maintenance, and medication adherence, • Support quality initiatives by closing care gaps in alignment with established metrics and clinical guidelines, • Maintain accurate, timely documentation within the EHR (experience with Allscripts Pro is a plus), • Assist with appointment scheduling, chart preparation, and Medicare Annual Wellness Visits, • Contribute to daily clinic operations as needed, including triage support, COVID testing, CGM placement/upload, and related tasks, • Track performance metrics, generate monthly CCM/APCM reports, and complete assigned administrative and clinical tasks Qualifications & Preferred Experience • Authorized to work in the United States (visa sponsorship not available), • International Medical Graduates (IMGs) who are not pursuing residency—or willing to commit to at least two years prior to applying—are strongly encouraged to apply, • Medical Assistant background preferred; CCM experience highly valued, • Strong interpersonal, communication, and patient-engagement skills, • Experience with motivational interviewing and patient education strategies, • Comfortable working with diverse patient populations and complex care needs, • Self-motivated, detail-oriented, and highly organized with excellent time-management skills, • Bilingual in English and Spanish is a plus, • Familiarity with DME coordination, home health services, and EHR systems (Allscripts Pro preferred)Company DescriptionWe are a thriving, patient-centered primary care and holistic medicine practice in Dallas, Texas, recognized for excellence in both care and culture. Our practice has been voted Best Medical Practice by D Magazine multiple times, reflecting our unwavering commitment to quality, innovation, and exceptional patient experiences. We offer a warm, supportive, and collaborative work environment where team members are valued, empowered, and encouraged to grow. We are seeking an experienced, enthusiastic, and dependable Medical Receptionist who takes pride in professionalism, teamwork, and being a welcoming presence for every patient who walks through our doors.We are a thriving, patient-centered primary care and holistic medicine practice in Dallas, Texas, recognized for excellence in both care and culture. Our practice has been voted Best Medical Practice by D Magazine multiple times, reflecting our unwavering commitment to quality, innovation, and exceptional patient experiences. We offer a warm, supportive, and collaborative work environment where team members are valued, empowered, and encouraged to grow. We are seeking an experienced, enthusiastic, and dependable Medical Receptionist who takes pride in professionalism, teamwork, and being a welcoming presence for every patient who walks through our doors.