CCM Care Coordinator- Rockford

Community Physicians is a well-established, patient-centered healthcare group dedicated to providing high-quality, compassionate care throughout Illinois.

Position Summary

We are seeking a detail-oriented Chronic Care Management (CCM) Care Coordinator to support approximately 200 patients enrolled in our primary care clinic's CCM program. This role focuses on monthly patient outreach, care coordination, medication follow-up, and accurate documentation of qualifying CCM services and time.

Key Responsibilities

• Conduct monthly patient outreach to assess care needs and follow up on chronic conditions.
• Document patient interactions, qualifying CCM activities, and time in the EHR.
• Support medication reconciliation and adherence follow-up, escalating concerns to the clinical team.
• Coordinate appointments, referrals, and follow-up after hospital or emergency department visits.
• Identify patient needs and communicate concerns to the supervising provider.
• Maintain accurate records and follow CCM documentation, consent, and billing requirements.

Required Qualifications

• Experience in a medical office, healthcare coordination, or patient support.
• Strong communication, organization, and documentation skills.
• Proficiency with electronic health records and basic computer applications.
• Ability to recognize concerns that require escalation to a licensed clinician.
• Understanding of patient confidentiality and HIPAA requirements.

Preferred Qualifications

• Certified Medical Assistant (CMA/RMA) or prior CCM experience.
• Familiarity with Medicare CCM billing and documentation.

Important Role Requirements

The employee must perform only duties permitted by their qualifications and applicable Illinois requirements. Only eligible, properly documented CCM service time may be counted toward billing. Clinical decisions and care-plan management remain with the supervising practitioner and appropriate clinical staff.