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Medical assistant ccm chronic care management

Desert Ridge Family Physicians·Phoenix, Arizona

$19 - $22/hr·Full Time·Hybrid·2-5 yrs·Posted 11 days ago
Practice for this role

About the role

Manage a panel of CCM and TCM patients through outreach, education, and care coordination to improve health outcomes. Document all activities in the EHR and collaborate with physicians and clinical staff to execute patient care plans.

Benefits

  • 401(k) matching
  • Bonus based on performance
  • Competitive salary
  • Dental insurance
  • Health insurance
  • Paid time off
  • Training & development
  • Vision insurance
  • Chronic care management
  • Manage a panel of CCM and TCM patients, ensuring timely outreach, documentation, and completion of required program elements.
  • Conduct patient outreach, follow-ups, and education to support chronic disease management.
  • Assist with medication reconciliation, referrals, and care coordination.
  • Support patients in navigating appointments, labs, imaging, and community resources.
  • Document all care management activities accurately and consistently in the EHR.
  • Provide care management, including phone-based outreach and in office patient support as needed.
  • Care Coordination & Team Collaboration
  • Work closely with physicians, supervisors, and clinical staff to support patient care plans.
  • Follow established CCM and TCM workflows to ensure consistency and compliance.
  • Escalate concerns, barriers, or process improvement ideas through leadership channels.
  • Participate in team meetings and ongoing training.

What we are looking for

Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role.

Patient centered and Team oriented

Medical Assistant experience preferred .

Organized, dependable, and able to work independently within defined workflows.

Able to follow structured workflows while maintaining strong attention to detail and accountability for assigned tasks.

Understands role responsibilities and maintains appropriate professional boundaries within a team-based care model.

Able to manage a high-volume workload, prioritize tasks effectively, and meet deadlines in a fast-paced environment.

Communicates clearly and proactively with leadership regarding patient needs, barriers, and workflow concerns.

Open to feedback, coaching, and professional development.

Experience with Athena EHR or similar systems preferred.

Why You’ll Love Working Here

Supportive leadership with clear expectations, structured workflows, and accountability.

Established systems that allow you to focus on patient care without unnecessary chaos.

Opportunities to build skills in CCM, TCM, and care coordination.

A collaborative environment that values teamwork, consistency, and growth.

Meaningful work that helps reduce hospitalizations and improve patient outcomes.

This role requires strong time management, attention to detail, and the ability to work within established processes.

We offer full medical benefits Paid 100% for employee 401k w/ 4% Match at 6 months competitive salary & PTO

Requirements

Requires experience in care coordination or chronic care management, with Medical Assistant experience preferred. Candidates must be organized, able to handle high-volume workloads, and proficient in EHR systems like Athena.

  • professional certificate
  • Time Management
  • Patient Education
  • Care Coordination
  • Patient Outreach
  • Interdisciplinary Collaboration
  • EHR Documentation
  • Chronic Care Management
  • Medication Reconciliation
  • Clinical Workflow Management
  • Athena EHR

Posting details

Employment type
Full Time
Work arrangement
Hybrid
Experience
2-5 yrs
Salary
$19 - $22/hr
Location
Phoenix, Arizona
Posted
Jul 17, 2026
Application
Employer website
DR

Hiring organization

Desert Ridge Family Physicians

Desert Ridge Family Physicians is hiring in Phoenix, Arizona. It operates in hospitals and health care. Team size: 11-50 employees. Headquarters: Phoenix, Arizona. This opening is listed as full_time.

Salary listed on 2 jobs
IndustryHospitals and Health Care
Size11-50 employees
HQPhoenix, Arizona
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Market context

Arizona nursing roles need active credentials

Arizona nursing roles are often competitive in psychiatric inpatient and geriatric med/surg settings, where employers look for current licensure, CPR or BLS certification, and a Level 1 Fingerprint Clearance card. Experience in behavioral health or geriatric care can strengthen an application. This platform’s job requirements and benefits are AI-summarized from the original posting, helping you review details faster before applying. If you are interested, confirm your Arizona license and clearance status first.

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