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LPN - Chronic Care Management Coordinator II

LPN - Chronic Care Management Coordinator II

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Our Chronic Care Management Coordinator II (LPN) position is a telephonic position located in Clearwater, FL.  The Chronic Care Management Program provides Chronic Care Management (CCM) to patients with two or more chronic diagnoses. CCM LON collects patient-centric health information to identify gaps in care and chronic risks.  The CCM program requires the development of a Patient-Centric Care Plan that provides goals and interventions to implement, monitor and support the needs of the patient as defined by the PCP. Collaboration with the primary care provider to ensure all care needs are addressed and interventions are clinically appropriate is an essential program function. The CCM program supports the patient through the continuum of care to promote the highest level of quality care. Patient CCM interventions are at a minimum monthly with updates of a PCP approved Care Plan.



Essential Duties and Responsibilities:

  • Educate the patient in the role of the care coordinator with collaboration of primary care physician.
  • Provide an initial risk identification function gathering all the clinical elements necessary to determine Patient-Centric Care Plan.
  • Monitor recidivism in ER and inpatient utilization.
  • Evaluation transition care needs for documented recidivism and implement interventions to address failures of transitional care.
  • Work with patient to plan and monitor their care as determined by the PCP and/specialist. from setting to setting by.
  • Promote timely access to medically necessary and appropriate care.
  • Promote compliance with transitional care, PCP/Specialist office visits.
  • Perform medication reconciliation and promote compliance with medication (medication adherence).
  • Act as a patient advocate, liaison and information resource.
  • Provide chronic care education for chronic/complex conditions as determined.
  • Monitor and report outcomes to Care a Plan goals and interventions at a minimum monthly.
  • Facilitate patient access to appropriate medical and specialty providers.
  • Cultivate and support primary care and specialty provider who determine the care needs of the patient.
  • Provide culturally appropriate education.

Other Responsibilities:

  • Adheres to the policies and procedures of Community Health Solutions of America, Inc.
  • Maintains strict confidentiality of client, company and personnel information
  • Demonstrates a strong commitment to the mission and values of the organization
  • Adheres to company attendance standards
  • Performs other duties as assigned

Supervisory Responsibilities:   None



  • 3 to 5 years’ experience in, clinical or community resource setting (care coordination experience is desirable).
  • Motivation interviewing desirable.
  • Proficiency in communication technologies for example email, cell phone, and EMR.
  • Highly organized with ability to keep accurate notes and records.
  • Experience with IT reports, Microsoft XL is desirable.
  • Knowledge of community and healthcare resources desirable.

Education and/or Experience:

Graduation from an accredited school for licensed practice nurse


Certificates, Licenses, Registrations: 

Current LPN licensure in Florida and may be required to become licensed in other states in which business in conducted.
LPN Supervisory certificate required.



  • Strong organizational and interpersonal skills
  • Excellent written and verbal communication skills
  • Detail oriented
  • Ability to multi-task and work independently

Computer Skills:

Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook. Ability to type care coordination documentation directly into system.

Environmental Factors/Physical Demands:

Work is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.