Chronic Care Coordinator

Job Description

Location: Fort Worth, TX

TalentLNX is partnering with a mission-driven healthcare organization in Fort Worth, Texas, to hire a dedicated and detail-oriented Chronic Care Coordinator (CCM). This full-time, onsite position plays a critical role in delivering proactive care coordination to patients living with multiple chronic conditions.

The ideal candidate is a healthcare professional who brings strong organizational skills, clinical understanding, and a patient-first mindset. This is a key opportunity for someone who is passionate about building relationships, improving outcomes, and supporting patients in managing their long-term health.

Responsibilities:

• Patient Engagement: Maintain consistent, monthly outreach to enrolled patients with two or more chronic conditions to assess their status, reinforce treatment plans, and offer health education and support.
• Care Planning: Create and regularly update individualized, patient-centered care plans in collaboration with the patient, provider, and interdisciplinary team.
• Care Coordination: Serve as a liaison between patients, providers, specialists, pharmacies, and community resources to ensure aligned, effective care delivery.
• Documentation: Record all patient interactions, interventions, and care plan changes accurately and promptly in the electronic health record (EHR), in accordance with CMS and organizational guidelines.
• Monitoring & Follow-Up: Track progress toward patient goals, address care gaps, and escalate issues to clinical leadership when needed.
• Compliance & Billing Support: Ensure documentation meets Chronic Care Management program requirements and contributes to accurate billing under CMS regulations.

Work Environment:

The CCM Coordinator works onsite at a community-based healthcare facility focused on collaboration and whole-person care. This team-centered environment supports proactive outreach and encourages close coordination with clinical staff to improve continuity of care and long-term outcomes. The organization values clear communication, shared purpose, and commitment to preventative care.

Qualifications:

• Education: Associate or Bachelor’s degree in Nursing, Social Work, Health Sciences, or a related field preferred
• Experience: Minimum of 2 years of experience in care coordination, case management, or chronic disease support
• Knowledge: Familiarity with chronic conditions such as diabetes, hypertension, COPD, CHF, and the CMS Chronic Care Management model
• Technical Skills: Proficiency in using EHR platforms and Microsoft Office
• Soft Skills: Exceptional communication, follow-up, and time-management skills with a patient-centered approach
• Certifications: CCM or Case Management certification preferred or willingness to obtain within 12 months

Schedule 

• Full-time, onsite
• Monday – Friday, 8:00 AM – 5:00 PM
• Standard business hours, no weekend or on-call responsibilities

Salary Range: Compensation for this role ranges from $50,000 to $60,000 per year (approximately $24.00 to $29.00 per hour), depending on experience and qualifications.

Interview Process:

• Initial Screening – TalentLNX Recruiting Team
  A 20–30 minute phone conversation designed to learn more about your background and career goals. We’ll share additional details about the role, clarify expectations, and ensure this opportunity aligns with what you’re seeking in your next position—whether it’s culture, compensation, growth potential, or long-term career direction.

• Second-Round Interview – Hiring Manager (CCM Program Supervisor or Clinical Operations Leader)
  A virtual interview focused on your chronic care coordination experience, communication style, and ability to manage a patient panel. You may be asked to walk through real-world examples or situational scenarios.

• Final Interview – Onsite Meeting with Key Team Members
  An in-person meeting with 1–2 members of the care coordination or clinical team. Because where you work—and who you work with—matters just as much as the work you do, this step ensures alignment in values, workflow, and team dynamics.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and prohibits discrimination and harassment of any kind. We are dedicated to building a diverse workforce and fostering an inclusive work environment where all employees and candidates are treated with respect and dignity. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or any other protected status under applicable law. We actively seek to recruit, develop, and retain talented individuals from diverse backgrounds, and we encourage all qualified candidates to apply for our job opportunities.